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PRINCIPLES  AND  PRACTICE 


OF 


DENTAL   SURGERY 


THE 


UBRARY 
SAk  1 IMORE  COLLEGE  OF 

Dental  surgery 


PRINCIPLES  AND  PRACTICE 


OP 


DENTAL  SURGERY, 


BY 


CHAPm  A.  HARRIS,  M.D.,D.D.S., 

PROFESSOR     OF     THE     PRINCIPLES     AND    PRACTICE     OF    DENTAL     SUEGEKY    IN     THE     BALTIMORE 
COLLEGE  ;    MEMBER    OP  THE   AMERICAN    MEDICAL   ASSOCIATION  ;     AUTHOR   OF   DIC- 
TIONARY   OF   MEDICAL   TERMINOLOQY,    DENTAL   SURGERY   AND    THE 
COLLATERAL  SCIENCES,    ETC.,   ETC. 


SEVEN^TII     EDITION: 

ENLAKGED     AND     IMPROVED 


WITH 

TWO   HUNDRED   AND   SEVENTY   ILLUSTRATIONS. 


PHILADELPHIA: 

LINDSAY     &     BLAKISTON 
1858. 


Enteeed,  according  to  the  act  of  Congress,  in  the  year  one  thousand  eight  hun- 
dred and  fifty-eight,  by  Lindsay  &  Blakiston,  in  the  Clerk's  OflSce  of  the  District 
Court  of  the  Eastern  District  of  Pennsylvania. 


JOHN     W.     WOODS,    PBINTBB, 
nALTIUORE. 


H'e^-^s 


3iomed 

100 


THOMAS     E.     BOND,M.  D. 

PROFESSOR   OF  SPECIAL   PATHOLOGY   AND   THERAPEUTICS   IN    THE   BALTIMORE    OOLLEOE    OF 
DENTAL     StTRGERT, 

AS    A    TOKEN    OF    GRATITUDE    FOR    MUCH    KINDNESS,    AND    AS    A 

TESTIMONY    OF    RESPECT    AND    ESTEEM    FOR    GREAT 

PROFESSIONAL     AND     PRIVATE     WORTH, 

THIS    VOLUME 


IS     RESPECTFULLY     DEDICATED, 

BY     HIS     FRIEND, 

AND      OBEDIENT     SERVANT, 

THE     AUTHOR. 


PREFACE 


TO     THE     SEVENTH     EDITION 


In  revising  his  Principles  and  Practice  of  Dental  Sur- 
gery for  a  Seventh  Edition,  the  author  trusts  that  no 
abatement  of  effort  will  be  discovered  on  his  part  to 
render  it  every  way  worthy  of  a  continuance  of  the 
approbation  it  has  hitherto  received.  Nearly  every 
page  has  been  carefully  revised,  and  additions  have 
been  introduced  throughout  the  entire  work.  Three 
new  chapters  and  a  number  of  illustrative  cuts  have 
also  been  added.  In  short,  he  believes  that  no  val- 
uable improvement  or  discovery,  coming  within  the 
scope  of  this  work,  has  been  omitted  in  the  present 
edition. 


CHAPIN    A.    HARRIS. 


N'o.  51  North  Chari,es-st. 
Baltimore,  Stpt.  185 


S-ST.  1 

58.     j 


PREFACE 


TO     THE     FIFTH      EDITION 


The  Fourth  Edition  of  this  work  having  been  dis- 
posed of,  a  Fifth  is  called  for.  In  this,  the  author  has 
endeavored,  as  he  did  in  each  of  the  preceding  editions, 
to  present  a  faithful  expos6  of  the  state  of  the  Science 
and  Art  of  Dental  Surgery  up  to  the  time  of  its  publi- 
cation. The  improvements  introduced  into  it,  will, 
he  believes,  be  found  fully  if  not  more  than  equal  to 
those  of  any  of  the  preceding  editions.  The  whole 
work  has  been  revised,  and  numerous  additions  made 
to  almost  every  chapter.  In  the  part  devoted  to  Me- 
chanical Dentistry  three  new  chapters  have  been 
added. 

The  author  indulges  the  hope  that  his  efforts  to  keep 
pace  with  the  progress  of  the  art  will  be  found  satis- 
factory to  his  readers,  and  that,  independently  of  the 
advantages  they  may  find  from  the  added  matter,  they 
will  be  gratified  to  perceive,  in  the  necessity  for  it,  the 
evidence  of  a  progress  in  Dentistry  most  cheering  to 
all  who  desire  to  see  this  branch  of  Surgery  rescued 
from  the  domain  of  ignorant  empiricism. 


PREFACE.  IX 

The  great  improvement  made  within  the  few  years 
past,  gives  good  reason  to  expect  that  this  department 
of  Medicine  will  soon  receive  the  public  and  profes- 
sional consideration  it  deserves.  To  be  instrumental 
in  bringing  about  a  result  so  desirable  is  the  sincere 
and  long  cherished  hope  of  the  author. 


PREFACE 


TO      THE     SECOND     EDITION. 


In  submitting  to  the  profession  a  Second  Edition  of 
his  Dental  Practice,  the  author  is  happy  to  avail  him- 
self of  the  opportunity  to  express  his  grateful  appre- 
ciation of  the  approbation  which  the  First  has  received. 
He  trusts  that  the  additions  which  he  has  made  to  the 
primary  work  will  make  the  one  now  presented  still 
more  acceptable.  The  alteration  in  the  plan,  which 
has  resulted  from  the  effort  at  improvement,  has,  how- 
ever, rendered  a  slight  change  of  title  necessary,  in 
order  to  express  the  character  of  the  present  book. 

In  the  First  Edition,  the  Anatomy  of  the  Mouth  was 
omitted,  because  a  thorough  knowledge  of  it  can  be 
obtained  from  works  on  General  Anatomy.  But  it 
has  been  suggested  that  such  works  may  not  be   at 


X  PREFACE. 

hand  when  wanted  by  the  dental  student,  and  the 
author  has  thought  it  better  to  furnish  a  description  of 
the  several  structures  which  enter  into  the  formation 
of  this  cavity.  He  has,  however,  confined  himself  to 
brief  expositions  of  the  parts  ;  not  wishing  to  encum- 
ber the  work,  or  distract  the  student  with  the  consid- 
eration of  matters  foreign  to  the  purpose  for  which  it 
was  written,  and  for  which  he  trusts,  it  will  be  read. 
He  is  indebted  to  Bourgery's  Anatom}^,  Quain  and 
Wilson's  Anatomical  Plates,  Wilson's  Anatomy,  and 
Smith  and  Horner's  Anatomical  Atlas,  for  a  number 
of  the  illustrations  used  in  this  part  of  the  work. 

The  second  and  fifth  parts  embody  the  substance  of 
two  papers,  by  the  author,  which  were  written  subse- 
quently to  the  publication  of  the  first  edition.  The 
subjects  of  them  came  properly  within  the  plan  of  the 
present  work. 

The  object  of  the  author  in  the  preparation  of  this 
edition  has  been  to  provide  a  thorough  elementary  trea- 
tise on  Dental  Medicine  and  Surgery,  which  might  be 
a  text  book  for  the  student  and  a  guide  to  the  more 
inexperienced  practitioner,  and  he  hopes  that  the  mod- 
ifications he  has  introduced,  and  the  additions  he  has 
made,  will  entitle  it  to  be  so  considered,  at  least,  until 
an  abler  hand  shall  prepare  a  better. 


LIBRARY 

BALTIMORE  COLLEGE  Of 

DENTAL  SURGERY 


CON  T  E  N"  T  S  . 


>      PART     FIRST. 

Page. 

Anatomy  and  Phtsioloqt  of  the  Mouth, 27 

Elements  of  the  Mouth,             27 

CHAPTER   FIRST. 

Organs  of  Prehension,            28 

Origin  and  Insertion  of  these  Muscles  or  their  Attachments,         .         .  29 

1.  Levator  Labii  Superioria  Alasque  Nasi,              ....  29 

2.  Levator  Anguli  Oris,              29 

3.  Depressor  Labii  Inferioris, 29 

4.  Depressor  Anguli  Oris, 30 

5.  Zygomaticus  Major,            30 

6.  Zygomaticus  Minor, 30 

7.  Buccinator, 30 

8.  Orbicularis  Oris,              30 

9.  Depressor  Labii  Superioris, 30 

10.  Levator  Labii  Inferioris, 30 

CHAPTER  SECOND. 

(Jegans  of  Mastication, 31 

Passive  Organs  of  Mastication,              31 

The  Superior  Maxillary  Bones, 31 

Inferior  Maxillary  Bone, 36 

The  Palate  Bones, 39 

The  Teeth, 40 

The  Temporary  Teeth, 41 

The  Permanent  Teeth,              42 

The  Pulp, 43 

The  Dentine,             46 

The  Enamel, 54 

The  Cementum, 57 


Xll  CONTENTS. 

Page. 

Description  of  Teetb  belonging  to  each  Class, 6!) 

The  Incisors,             59 

The  Cuspidati,             61 

The  Bicuspids, 62 

The  Molars, 63 

Articulation  of  the  Teeth,               65 

Difference  between  the  Teu]porar_v  and  Permanent  Teeth,        ...  65 
lielations  of  the  Teeth  of  the  Upper  to  those  of  the  Lower  Jaw,  when  the 

Mouth  is  closed, 66 

Active  Organs  of  Mastication, 67 

The  Temporal  Muscle,               68 

The  Masseter  Muscle,            68 

Pterjgoideus  Externus,             69 

Pterygoideus  Internus, 70 

CHAPTER  THIRD. 

Okqans  of  Insalivation, 71 

The  Parotid  Gland, .  71 

The  Submaxillary,             72 

The  Sublingual  (Jlands, 73 

The  Mucous  Glands, 73 

CHAPTER   FOURTH. 

Croaks  of  Dkglutition, 75 

The  Pharynx, 75 

The  Soft  Palate, 77 

The  Tongue,              80 

The  Mucous  Membrane  Lining  the  Mouth, 84 

The  Gums, 85 

The  Alveolo-Dental  Periosteum, .86 

CHAPTER  FIFTH. 

Bi.ooD-ViissEi.s  OF  THE  Mouth, 88 

Arteries  of  Prehension, 89 

Arteries  of  Mastication, 90 

Arteries  of  Insalivation, 92 

Arteries  of  Deglutition, 92 

Branches  of  the  External  Carotid  Artery  as  they  arise  in  Numer- 
ical Order, 93 

The  Veins, 94 

CHAPTER   SIXTH. 

Thf.  Nf.kvks  ok  thf.  Mouth, 95 

The  Superior  Maxillary  Nerve, 97 

Inferior  Maxillary  Nerve,              100 

The  Facial  Nerve,              102 

Anatomical  Relations  of  the  Mouth, 104 

Physiological  Relations, 105 


CONTENTS.  Xlll 


Page. 


CHAPTER  SEVENTH. 


Origin  and  Formation  of  the  Teeth,          .....  108 

Formation  of  the  Dentine,                   ......  120 

Formation  of  the  Enamel  of  the  Teeth,               .            .             .            .  125 

Formation  of  the  Cementum,  or  Crusta  Petrosa,     ....  128 

CHAPTER  EIGHTH. 

First  Dentition,  ........      130 

Eruption  of  the  Temporary  Teeth,  .....  130 

Morbid  Effects  resulting  from  First  Dentition,         ....       134 

CHAPTER  NliSTH. 
Shedding  of  the  Temporary  Teeth,  .....      139 

CHAPTER   TENTH. 

Second  Dentition,  ........      144 

Accretion  of  the  Jaws,      .......  148 

CHAPTER  ELEVENTH. 
Method  of  Directing  Second  Dentition,         .....      153 

CHAPTER   TWELFTH. 

luaEGOLARITY  OF  THE  TeETH,     .......    159 

Treatment,  .  .  .  .  .  .  .  .  162 

CHAPTER  THIRTEENTH. 

Deformity   from   Excessive   Development   of   the   Teeth   and  Alveolar 

RiDGB  of  Lower  Jaw,  ......      175 

Treatment,  ........  175 

CHAPTER   FOURTEENTH. 

Protrusion  of  the  Lower  Jaw,  ......      178 

Treatment,  ........  178 

CHAPTER   FIFTEENTH. 

Peculiarities  in  the  Formation  and  Growth  of  the  Teeth,  .    *       .      181 

CHAPTER  SIXTEENTH. 

Osseous  Union  of  the  Teeth,  ......      186 

CHAPTER  SEVENTEENTH. 
Supernumerary  Teeth,  .......      188 

CHAPTER  EIGHTEENTH. 
Third  Dentition,  ........      190 


XIV  CONTENTS. 

Page. 

PART     SECOND. 

PnTsiCAi,  Charactekistics  of  the  Hdman  Teeth,  Gums,  Salivary   Calcct- 

LU8.  Lips,  Tongue,  and  the  Fluids  of  the  Mouth,        .  .  .      197 

CHAPTER  FIPvST. 
Ghseral  Cossiderations,  .......       199 

CHAPTER   SECOND, 
Physical  Charactekistics  of  the  Teeth,  .....       212 

CHAPTER  THIRD. 
Physical  Characteristics  of  the  Gcms,  .....      223 

CHAPTER   FOURTH. 
Physical  Characteristics  of  Salivary  Calculus,      ....      234 

CHAPTER   FIFTH. 
Physical  Characteristics  of  the  Fluids  of  the  Mouth,  .  .      240 

CHAPTER  SIXTH. 
Physical  Characteristics  of  the  Lips,  .....      243 

CHAPTER   SEVENTH. 
Physical  Characteristics  of  the  Tongue,       .....      246 


PART     THIRD. 

Diseases  of  the  Teeth  and  their  Treatment— Dislocation  of  the  Lower 

J-^w,          .........  253 

Diseases  Sf  the  Teeth,          .......  255 

CHAPTER  FIRST. 

Caries  of  thb  Teeth,        ........  256 

Diflercnces  in  the  Liability  of  nifferent  Teeth  to  Decay,        .            .  259 

Causes  of  Caries,         .            .            .            .            .             •            ,            ,  205 

Prevention  of  Caries,        .......  275 

Treatment  of  Caries,               .......  276 

CHAPTER   SECOND. 

FiLiNii  Teeth,                      •            .            .            .            ,  278 


CONTENTS.  XV 


CHAPTER  THIRD. 

Filling  Teeth, 288 

Materials  Employed  for  FilliDg  Teeth, 290 

Instrumtnts  for  Forming  the  Cavity,  .         .         .         .         .         ,         295 

Manuer  of  Forming  the  Cavity,  299 

Instruments  for  Intioducing  Gold  Foil,  30.3 

Manner  of  Introducing  and  Consolidating  Gold  Foil,  and  Finishing  the 

Surface  of  the  Filling, 305 

CHAPTER    FOURTH. 

Filling  Individual  Cavities  in  Teeth, 310 

Filling  the  Superior  Incisors  and  Cuspidati,  .....  310 

Filling  the  Superior  Molars  and  Bicuspids,  .....  321 

Filling  the  Infeiior  Incisors  and  Cuspidati, 328 

Filling  the  Inferior  Molars  and  Bicuspids,  330 

CHAPTER     FIFTH. 

Filling  Teeth  when  the  Lining  Membrane  is  Exposep,  .        .         .  337 

CHAPTER    SIXTH. 

Filling  Pclp  Cavities  and  Roots  of  Teeth, 346 

CHAPTER    SEVENTH. 

Filling  Teeth  with  Ckystalline  and  Sponge  Gold,  ....  360 

Instruments  Employed  in  the  Operation, 360 

Introducing  and  Consolidating  the  Gold, 365 

CHAPTER    EIGHTH. 

Building  on  the  Whole  ok  Part  of  the  Crown  of  a  Tooth,  .        .  367 

CHAPTER    NINTH. 

TooTu-AcHE, "  374 

Causes, 374 

Treatment, 381 

CHAPTER     TENTH. 

EXTIi ACTION   OF  Teeth, 385 

Indications  for  the  Extraction  of  Teeth, 387 

Instruments  Employed  in  the  Operation, 390 

Key  Instrument,        ...........  390 

Forceps, 392 

Manner  of  Using  the  Key  Instrument, 399 

Manner  of  Using  the  Forceps, 401 

Manner  of  Extracting  Roots  of  Teeth, 405 

Extraction  of  the  Temporai-y  Teeth, 411 

Uemorihage  after  Extraction, 411 


Xvi  CONTENTS. 

Paok. 
CHAPTER    ELEVENTH. 

The  Use  of  Anaesthetic  Aoents  in  the  Extraction  of  Teeth,         .        .  414 

CHAPTER    TWELFTH. 

Ateopht  of  the  Teeth, 421 

Causes, 427 

Treatment, 431 

CHAPTER    THIRTEENTH. 

Necrosis  of  the  Teeth, 432 

Causes, 433 

Treatment,           433 

CHAPTER    FOURTEENTH. 

Exostosis  of  the  Roots  of  the  Teeth,           .......  435 

Causes, .  437 

Treatment, 438 

CHAPTER    FIFTEENTH. 

Spina  Ventosa  ok  the  Teeth, 439 

Causes, 440 

Treatment,            •        ...  440 

CHAPTER    SIXTEENTH. 

Dbnudino  op  tete  Teeth, 442 

Causes, 443 

Treatment, .        .        ■        .  446 

CHAPTER    SEVENTEENTH. 

Spontaneous  Abrasion  of  the  Cuttinq  Edges  of  the  Front  Teeth,         .  446 

Causes, 448 

Treatment, 449 

CHAPTER    EIGHTEENTH. 

Mechanical  Abrasion  of  the  Teeth, 460 

CHAPTER    NINETEENTH. 

Fractures  and  other  Injuries  of  the  Teeth  from  Mechanical  Violence,  452 

CHAPTER    TWENTIETH. 

Diseases  of  the  Dental  Pulp  and  Periosteum, 45(5 

Irritation,       ............  467 

Inflammation,             464 

Spontaneous  Disorganization, 475 

Fungous  Growth, 476 

Ossification, 477 

Inflammation  of  the  Dental  Periosteum, 478 

CHAPTER    TWENTY-FIRST. 

Dislocation  of  the  Lower  Jaw, 481 


CONTENTS.  XVU 


PART    FOURTH. 


Page. 

Salivary  Calculus — Diseases  of  the  Gums  and  Alveolar  Processes,  and 

THEIR  Treatment, 487 

CHAPTER    FIRST. 

Salivary  Calculus, 489 

Chemical  Constituents  of  Salivary  Calculus,            490 

Origin  and  Deposition  of  Salivary  Calculus, 491 

Eflfects  of  Salivary  Calculus  upon  the  Teeth,  Gums  and  Alveolar  Pro- 
cesses,                496 

Manner  of  Removing  Salivary  Calculus,           ....               .  497 

CHAPTER    SECOND, 

Diseases  op  the  Gums,            500 

Acute  Inflammation  of  the  Gums, 502 

Chronic  Inflammation  and  Tumefaction  of  the  Gums  attended  by  Re- 
cession of  their  Margins  from  the  Teeth, 503 

Causes, 506 

Treatment, 508 

Morbid  Growth  of  the  Gums,            513 

Causes, 514 

Treatment, 514 

Mercurial  Inflammation  of  the  Gums, 515 

Treatment, 516 

Ulceration  of  the  Gums  of  Children,  attended  with    exfoliation  of  the 

Alveolar  Processes,           617 

Causes, 519 

Treatment, 520 

Adhesion  of  the  Gums  to  the  Cheeks, 521 

CHAPTER    FIFTH. 

Tumors  and  Excrescences  of  the  Gums  and  Alveolar  Processes,        .  522 

Causes, 622 

Treatment, 524 

CHAPTER    SIXTH. 

Alveolar  Abscess, 630 

Causes, 632 

Treatment,            632 

CHAPTER    SEVENTH. 

Necrosis  and  Exfoliation  of  the  Alveolar  Processes,         .        .        .  538 

Causes, 642 

Treatment, 542 

2 


Xvili  CONTENTS. 

CHAPTER     EIGHTH. 

Page. 

Gradual  Destruction  of  the  Alveolar  Processes, 543 

Causes, 544 

Treatment, 545 

CHAPTER    NINTH. 

Displacement  of   the  Teeth  by  a  Deposit    of   Osseous   Matter  in  their 

Sockets, 547 

Causes, 548 

Treatment,  548 


PART     FIFTH 


Diseases  of  the  Maxillary  Sinus,  and  their  Treatment, 


549 


CHAPTER    FIRST. 


Preliminary  Remarks, 


551 


CHAPTER     SECOND. 

Inflammation  of  the  Lining  Membrane  op  the  Maxillary  Sinus, 

Symptoms, 

Causes, 

Treatment, 


559 
560 
562 
562 


CHAPTER    THIRD. 


Purulent  Condition  of  the  Secretions 
LARY  Sinus, 
Symptoms, 


AND  Engorgement  of  the  Maxil- 


Causes, 

Treatment, 
Case  1st, 
Case  2d, 
Case  3d, 
Case  4th, 
Case  5  th, 
Case  6th, 
Case  7th, 
Case  8th, 
Case  9th, 
Case  10th, 


564 
568 
570 
571 
577 
578 
579 
580 
581 
582 
583 
586 
587 
587 


CHAPTER    FOURTH. 


Abscess  of  the  Maxillary  Sinus, 
Symptoms,        .        .        .        . 
Causes,         .... 
Treatment,        .... 
Case  11th,      . 


589 
592 
593 
593 
595 


CONTENTS.  XIX 


CHAPTER    FIFTH, 

Page. 

Ulceration  of  the  Lining  Membrane  of  the  Maxillary  Sinus,           .  599 

Symptoms, •         •  601 

Causes, 600 

Treatment, 602 

Case  12th, 605 

CHAPTER    SIXTH. 

Caries,  Necrosis  akd  Softening  of  the  Bony  Parietes  of  the  Maxillary 

Sinus, 608 

Symptoms, 609 

Causes, 610 

Treatment, 611 

Case  13th, 613 

Case  14th, 616 

CHAPTER    SEVENTH. 

Tumors  of  the  Lining  Membrane  and  Periosteum  of  the  Maxillary  Sinus,  617 

Symptoms, 621 

Causes, 622 

Treatment, 622 

Case  15th, 625 

Case  16th, 626 

Case  17th, 628 

Case  18th,  •        • 630 

Case  19th, 631 

CHAPTER     EIGHTH. 

Exostosis  of  the  Osseous  Parietes  of  the  Maxillary  Sinus,       .        .        .  637 

Symptoms, 640 

Causes, 641 

Treatment, 641 

Case  21st, 643 

Case  22d, 645 

CHAPTER    NINTH. 

Wounds  of  the  Osseous  Parietes  of  the  Maxillary  Sinus,  ,        .        .    647 

Treatment, 648 

Case  23d, 648 

CHAPTER    TENTH. 

Foreign  Bodies  in  the  Maxillary  Sinus,         ....•■.    651 


XX 


CONTENTS. 


P  AKT    SIXTH. 

Page. 

Mechanical  Dentistry, •  655 

Mechanical  Dentistry, 657 

CHAPTER    FIRST. 

Artificial  Teeth, 668 

CHAPTER    SECOND. 

Substances  Employed  foe  Artificial  Teeth, 662 

Human  Teeth, .        ■        •        •  662 

Teeth  of  Cattle, .  663 

Ivory  of  the  Tusks  of  the  Elephant  and  Hippopotamus,          •        •        •  664 

Porcelain  Teeth, 666 

CHAPTER    THIRD. 

Different  Methods  op  Applying  Artificial  Teeth,        .....  668 

Artificial  Teeth  Placed  on  Natural  Roots, 668 

Artificial  Teeth  Attached  to  a  Plate  with  Clasps,         .....  670 

Artificial  Teeth  with  Spiral  Springs, 671 

Atmospheric  Pressure,  or  Suction  Method  of  Applying  Artificial  Teeth,  672 


CHAPTER    FOURTH. 
Surgical  Treatment  of  the  Mouth  Preparatory  to  the  Application  or 


Artificial  Teeth, 


676 


CHAPTER    FIFTH. 
Manner  of  Preparing  a  Natural  Root  and  Securing  an  Artificial  Crown 


to  it, 


679 


CHAPTER    SIXTH. 

Manner  of  Refining  and  Alloying  Gold — Making  Plate,  Clasps,  Springs, 
etc.,  for  Artificial  Teeth,  and  Solper  Suitable  for  Uniting  the 
Different  Parts  of  a  Piece  of  Dental  Mechanism, 

Manner  of  Refining  Gold, 

Alloying  Gold, . 

Manner  of  Making  Springs  for  the  Support  of  Artificial  Teeth, 

Manner  of  Making  Gold  Plate, 

Manner  of  Making  Gold  Solder, 

Recipe  No.  1 — Fine  Flowing  Gold  Solder, 

Recipe  No.  2        "  "  «'  "  ... 

Recipe  No.  3        "         "  <«         «  .... 


690 
692 
696 
698 
701 
703 
704 
704 
704 


CONTENTS.  XXI 

CHAPTER    SEVENTH. 

Paoe. 

Wax  and  Plaster  of  Paris  Impressions  of  the  Mouth,  Plaster  Models — 

ALSO,  Metallic  Models  and  Counter-Models, 705 

Wax  Impressions, 705 

Plaster  of  Paris  Impressions,         ••••....•  709 

Plaster  Models, 711 

A  Metallic  Model  and  Counter-Model, 714 

CHAPTER    EIGHTH. 

Swaging  a  Plate  and  Soldering  Clasps  to  it, 719 

Fitting  the  Clasps, 720 

Soldering  Clasps  to  a  Plate,  .        .        •        .        .  •      ■        •        •        <    724 

CHAPTER    NINTH. 
Manner  or  Obtaining  an  Antagonizing  Model, 733 

CHAPTER    TENTH. 

Arranging,  Fitting,  Antagonizing,  and  Attaching  Porcelain  Teeth  to  a 

Plate — Finishing  and  Applying  the  Piece, 739 

Finishing  and  Applying  a  Plate  Mounted  with  Porcelain  Teeth,  •        745 

CHAPTER    ELEVENTH. 

Mounting  Natural  Teeth  upon  a  Plate,  ou  Metallic  Base,        .        .        •    749 

CHAPTER    TWELFTH. 

Dental  Substitutes  for  Special  Cases,  .•••.-.•  751 
An  Artificial  Central  Incisor  for  the  Upper  Jaw,  mounted  on  Plate,  with 

one  Clasp, 751 

An  Artificial  Central  Incisor,  Mounted  on  a  Plate  with  two  Clasps,  .  752 
Two  Artificial  Central  Incisors  for  the  Upper  Jaw,  Mounted  on  Plate,  with 

Clasps, 752 

Artificial  Incisors  and  Cuspidati  for  the  Upper  Jaw,  Mounted  on  Plate, 

with  Clasps, 753 

Two  Artificial  Bicuspids  for  the  Upper  Jaw,  Mounted  on  Plate,  with  one 

Clasp, 754 

Artificial  Bicuspids  and  First  Molars,  for  the   Upper   Jaw,  Mounted   on 

Plate,  with  Clasps, 754 

Artificial  Incisors,  Cuspids  and  Bicuspids  for  the   Upper  Jaw,  Mounted 

on  Plate,  with  Clasps, 755 

Artificial  Incisors,  Cuspids,  Bicuspids,  First  Right,  and  First  and  Second 

Left  Molars,  for  the  Upper  Jaw,  Mounted  on  Plate  with  one  Clasp,  756 
Artificial  Lateral  Incisors,  and  Left  Bicuspids  for  the  Upper  Jaw,  Mounted 

on  Plate,  with  two  Clasps  on  one  side, 756 

CHAPTER    THIRTEENTH. 

The  Teeth  to  which  it  is  most  proper  to  Apply  Clasps,  and  the  JIeass 
Necessary  to  Prevent  the  Injury  Liable  to  Result  fuom  tiieth 
Use, 758 


Xxii  CONTENTS. 

CHAPTER    FOURTEENTH, 

Paoe. 

Double  Set  of  Artificial  Teeth,  Mounted  on  Plate,  with  Spiual  Springs,  762 

CHAPEER    FIFTEENTH. 

Artificial  Teeth  Mounted  on  Suction  or  Atmospheric  Bases,     .        .        .  765 

Artificial  Teeth,  with  Gums  Mounted  on  Plate, 769 

CHAPTER    SIXTEENTH. 

Artificial  Teeth  Mounted  on  Cavity  Plates, 772 

CHAPTER  SEVENTEENTH. 

Porcelain  Block  Teeth, 779 

Materials  Used  in  Making  Porcelain  Block  Teeth,          ....  779 

Coloring  Materials, 781 

Composition  and  Preparation  of  Body, 786 

Composition  and  Preparation  of  Enamel, 787 

Antagonizing  Model  for  an  Upper  Set  of  Block  Teeth,           ...  792 
Manner  of  Making  a  Matrix  for  Moulding  the  Body,  Preparatory  to  Carv- 
ing the  Teeth,             793 

Moulding  and  Carving, 796 

Crucing,  or  Biscuiting, 797 

Insertion  of  the  Platina  Pins, 798 

Enameling,        ............  798 

Firing  and  Baking, 799 

Fitting  and  Attaching  the  Blocks  to  the  Plate, 801 

CHAPTER    EIGHTEENTH. 

Single   Porcelain  Teeth  Mounted  on  a  Metallic  Bass,  with   Continuous 

AuTiFiciAL  Gums, 805 

CHAPTER    NINETEENTH. 

CuEOPLASTic  Method  of  Mounting  Artificial  Teeth, 811 


PART    kSEVENTH. 

DisEAsKs  AND  Defects  of  the  Palatine  Organs, 829 

CHAPTER    FIRST. 

Diseases  of  the  Palate, 831 

Tumors  (if  the  Palate, 831 

Causes 833 

Treatment, 834 

Caries  and  Xccrosis  of  the  Bones  of  the  Palate,  and  Ulceration  of  the  Mu- 
cous Membrane, 837 


CONTENTS.  XXlll 

Tagb. 

Causes,               .........  839 

Treatment,               .••.....  839 

Inflammation  and  Ulceration  of  the  Velum  and  Uvula,      ■            .            .  842 

Causes,          .........  844 

Treatment,         .           .           •            .           .                       .            .            .  845 

CHAPTER    SECOND. 

Defects  op  the  Palatine  Organs,           ......  848 

Accidental  Defects,             .......  848 

Congenital  Defects,       ........  §49 

Functional  Disturbances  Resulting  from  Defects  of  the  Palatine  Organs,  851 

CHAPTER    THIRD, 

Manner  of  Remedying  Defects  of  tee  Palatine  Organs,     •            .           .  856 

Staphyloraphy,       ........  856 

Artificial  Obturators  and  Palates,       ......  864 

A  Simple  Palate,  or  Palate  Obturator,               .            .            •            .  867 
A  Palate  Plate,  or  Obturator,  with  a  Drum  upon  its  Upper  or  Convex 

Surface,            ........  868 

An  Artificial  Palate,  with  a  Velum  and  Uvula,       •           .            .           .  869 

Artificial  Palates  and  Obturators,  Complicated  with  Artificial  Teeth,  876 


PA.IIT     FIRST. 


AMTOMY  AND  PHYSIOLOGY  OF  THE  MOUTH. 

FIRST  AND  SECOND  DENTITION. 

IRREGULARITY  OF  THE  TEETH-ITS  TREATMENT. 

DEFORMITY  &  PARTIAL  LUXATION  OF  THE  LOWER  JAW. 

PECULIARITIES  IN   THE  FORMATION  AND   GROWTH  OF 
THE  TEETH. 

OSSEOUS  UNION  OF  THE  TEETH. 

THIRD  DENTITION. 


LIBRARY 

BALTIMDRI  COLLEGE  OF 

DENTAL  SURGERY 


PHINCIPLES  AND  PRACTICE 


OF 


DENTAL    SURGERY. 


PA.IIT     FIRST. 


AMTOMY  AND  PHYSIOLOGY  OF  THE  MOUTH. 

The  Mouth,  containing  the  Dental  Apparatus,  is  a  very 
complicated  j^iece  of  meclianism — forms  an  essential  part  of 
the  human  frame — has  the  widest  possible  range  of  sympa- 
thy— contains  a  great  variety  of  organs — and  performs  an 
equally  great  variety  of  functions. 

ELEMENTS   OF   THE   MOUTH. 

The  anatomical  elements  composing  the  mouth,  consist  of 
Bone,  Ligament,  Muscle,  Gland,  Vessel,  Nerve,  Cellular 
and  Adipose  Tissue  and  Mucous  Membrane. 

These  different  elements  combine  together  and  form  the 
various  organs  which  constitute  the  mouth. 

These  organs  I  shall  consider  in  their  physiological  order — 
thus  combining  their  anatomy  and  physiology — or  studying 
at  the  same  time  both  their  healthy  structure  and  function — 
a  plan  practically  taught  by  the  late  Professor  W.  R. 
Handy,  in  the  Baltimore  College  of  Dental  Surgery,  and 
which  commends  itself  by  being  the  most  natural,  interest- 
ing and  instructive. 


28 


ORGANS   OF    PREHENSION. 


The  mouth  is  bounded  above  by  the  palatine  processes  of 
the  superior  maxillary  and  palatine  bones — below  by  the 
tongue  and  mylo-hyoid  muscles — laterally  by  the  cheeks — 
anteriorly  by  the  lips — and  posteriorly  by  the  soft  palate 
and  fauces. 

The  mouth  contains  the  organs  of  taste,  and  is  concerned 
in  the  four  primary  stages  of  Digestion,  namely  : 

Prehension,  Mastication,  Insalivation  and  Deglutition — 
besides  being  engaged  in  the  intellectual  acts  of  speech  and 
expression. 


CHAPTER    FIRST. 


ORGANS  OF  PREHEXSIOK 


Pig.  1. 


This  class  of  organs  may  be 
said  to  commence  digestion,  and 
it  comprises  those  which  seize 
the  food,  and  introduce  and 
partly  retain  it  in  the  mouth. 

They  consist  of  the  Elevators, 
Depressors,  and  Sphinctor  Mus- 
cles of  the  mouth,  which  are  as 
follows : 

1.  Levator  labii  superioris 
alfeque  nasi,  j  j' 

2.  Levator  anguli  oris.  P 
These  two  elevate  the  upper 

lip  and  angle  of  the  mouth. 
3.  Depressor  labii  inferioris — or  quadratus  menti.   '  ' 

FiQ.  1.  A  front  view  of  tbo  muscles  of  the  face:  a  a  Anterior  bellies  of  occipito- 
frontalis  ;  h  b  Orbicularis  palpebrarum  ;  c  Pyramidalis  nasi ;  d  Compressor  nasi ; 
ee  and// Levator  labii  superioris  ala;que  nasi;  ^  i/ Zygomaticus  minor;  hh'Lj- 
gomaticus  major  ;  t  t  Masseter  muscle  ;  jj  Buccinator,  or  ti.x.i,peter's  muscle;  kk 
Orbicularis  oris;  Z  ?  Depressor  labii  inferioris;  m  Levator  menti;  n  n  Depressor 
anguli  oris ;  o  o  Levator  anguli  oris. 


ORGANS   OF   PREHENSION.  29 

4.  Depressor  anguli  oris — or  triangular  oris. 

These  two  antagonize  the  first  and  depress  the  lower  lip 
and  angles  of  the  mouth. 

5.  Zygomaticus  major,  /u  It 

6.  Zygomaticus  minor.   :    : 

7.  Buccinator.  '   ^ 

These  are  situated  to  the  outside  of  the  angles  of  the 
mouth — in  the  direction  from  the  angles  to  the  prominence 
of  the  cheek. 

Their  use  is  to  draw  the  angles  of  the  mouth  upwards  and 
outwards  towards  the  ear. 

8.  Obicularis  oris. 

This  is  the  sphincter  muscle  which  surrounds  and  closes 
the  mouth. 

9.  Depressor  labii  superioris. 

10.  Levator  labii  inferioris. 

The  one  depresses  the  upper  lip  against  the  teeth — the 
other  raises  the  lower  lip. 


ORIGIN  AND  INSERTION  OF  THESE  MUSCLES  OR  THEIR  ATTACHMENTS. 

1.  Levator  Labii  Superioris  Alceque  Nasi,  arises  by  two 
heads — first  from  the  nasal  process  of  the  superior  maxillary 
bone — second,  from  the  edge  of  the  orbit  above  the  infra- 
orbitar  foramen.  It  is  inserted  into  the  ala  nasi  or  wing  of 
the  nose  and  upper  lip. 


't> 


2.  Levator  Anguli  Oris,  arises  from  the  canine  fossa  of 
the  superior  maxillary  bone,  immediately  below  the  infra- 
orbitar  hole.  It  is  inserted  narrow  into  the  angle  of  the 
mouth. 

3.  Depressor  Labii  Liferioris,  arises  from  the  side  and 
front  of  the  inferior  maxilla  at  its  base,  and  is  inserted  into 
the  greater  part  of  the  lower  lip. 


30  ORGANS   OF    PREHENSION. 

4.  Depressor  Angiili  Oris,  arises  broad  and  fleshy  from 
the  base  of  the  lower  jaw  at  the  side  of  the  chin.  It  is  in- 
serted into  the  angle  of  the  mouth. 

5.  Zygomaticus  Major,  arises  long  and  narrow  from  the 
malar  bone,  near  the  zygomatic  suture.  It  is  inserted  into 
the  angle  of  the  mouth. 

6.  Zygomaticus  Minor,  arises  from  the  front  part  of  the 
malar  bone,  and  is  inserted  into  the  upper  lip,  above  the 
angle  of  the  mouth. 

This  muscle  is  sometimes  wanting — and  is  sometimes  a 
simple  slip  from  other  muscles. 

7.  Buccinator,  arises  from  the  upper  and  lower  jaws  as 
far  back  as  the  coronoid  and  pterygoid  processes,  and  from 
the  alveolar  ridge  as  far  forwards  as  the  bicuspid  teeth.  It 
is  inserted  into  the  angle  of  the  mouth. 

8.  Ohicularis  Oris.  This  muscle  has  no  bony  attach- 
ments— it  is  circular,  surrounds  the  mouth — and  consists  of 
two  planes  of  fibres,  one  for  the  upper — the  other  for  the 
lower  lip,  which  meet  at  the  angle  of  the  mouth. 

9.  Depressor  Lahii  Superioris,  arises  from  the  alveolar 
processes  of  the  incisor  and  canine  teeth  ;  and  is  inserted 
into  the  upper  lip  and  side  of  the  ala  nasi. 

10.  Levator  Labii  Inferioris,  arises  from  the  alveolar  pro- 
cesses of  the  incisor  teetli  of  the  lower  jaw.  It  is  inserted 
into  the  lower  lip  and  chin. 

See  Organs  of  Mastication  for  descriptions  of  bones  con- 
cerned with  these  muscles. 


CHAPTER    SECOND. 

ORGANS  OF  MASTICATION. 

Mastication,  as  the  term  implieS;,  is  a  process  of  chewing 
or  reducing  the  food,  when  introduced  into  the  mouth,  into 
minute  portions,  and  the  organs  under  this  head  are  the 
agents  or  instruments  which  effect  this  operation. 

The  organs  of  mastication  are  divided  into,  1st.  The  pass- 
sive.     2d.  The  active. 

PASSIVE  ORGANS  OP  MASTICATION. 

The  passive  organs  include  the  hones,  ligaments  and  teeth. 
The  principal  hones  are, 

1.  The  superior  maxillary  or  upj)er  jaw  bone. 

2.  The  inferior  maxillary  or  lower  jaw  bone. 

3.  The  palate  bones. 

THE  SUPERIOR  MAXILLARY  BONES. 

The  Superior  Maxillary  Bones,  being  two  in  number,  are 
in  pairs  and  united  on  the  median  line  of  the  face.  They 
occupy  the  anterior  uj)per  part  of  the  face,  are  of  very  irreg- 
ular/orm,  and  consist  of  a  body,  processes  and  foramina. 

The  body  is  the  central  part  of  the  bone  and  has  four  sur- 
faces, namely,  the  anterior  or  facial  surface,  the  posterior  or 
pterygoid,  the  superior  or  orbitar,  and  the  inferior  or  pala- 
tine surface. 

The  Anterior  Surface  is  irregularly  convex,  and  has  a 
depression  about  its  centre  just  above  the  canine  and  first 
bicuspid  teeth,  called  the  canine  fossa — immediately  above 
which  is  the  infra-orbitar  foramen  for  transmitting  an  artery 
and  nerve  of  same  name — its  upper  and  inner  edge  forms 
part  of  the  lower  margin  of  the  orbit — from  the  inner  ex- 


32 


ORGANS  OF   MASTICATION. 


tremity  of  which  proceeds  upwards  towards  the  nasal  and 
frontal  bones  a  long  and  rather  flat  process,  the  nasal  pro- 
cess of  the  superior  maxilla — it  is  of  a  pyramidal  form  ;  its 
posterior  edge  forming  the  internal  margin  of  the  orbit  and 
helping  to  make  the  lachrymal  groove  ;  its  anterior  edge 
receives  the  cartilages  of  the  nose  ;  its  upper  corresponds  to 

Fig.  2.  Fio.  3. 


the  nasal  bones,  and  its  summit  to  the  frontal,  while  its 
outer  surface  gives  attachment  to  muscles,  and  its  inner 
enters  into  the  formation  of  the  nose. 

Fig.  4. 

From  the  lower  edge  of 
its  anterior  surface,  the 
alveolar  processes  and  cav- 
ities are  formed — these 
consist  in  dei)ressions  of 
a  more  or  less  conical  form 
and  corresjiond  to  the 
number  of  teeth,  or  roots 
of  teeth,  they  are  intend- 
ed to  receive.     See  Fig.  4. 

Fig.  2.  a  The  body  of  the  left  superior  maxill.irj;  6  Canine  fossa;  c  Infra-orbi- 
tar  foramen  ;  d  Incisive  fossa ;  e  Harmonial  suture  of  the  two  bones  ;  /  Nasal  spine  ,: 
g  Semilunar  notch  of  anterior  nares  ;  h  Nasal  process  ;  i  Articulation  of  lachrymal 
bone ;  j  Malar  process ;  /.•  Tuberosity  of  superior  maxillary ;  I  Cavity  of  the  an- 
trum ;  m  Lachrymal  tubercle ;  jj  Orbitar  process. 

Fig.  3.  a  Nasal  surface  of  left  sui>erior  maxillary;  b  Opening  of  antrum;  c  In- 


ORGANS  OF  MASTICATION.  33 

The  bottom  of  each  of  these  cavities  is  perforated  by  a 
small  foramen^  for  the  passage  of  nerves  and  blood  vessels 
which  go  to  the  teeth.  The  alveolar  border  externally  pre- 
sents a  fluted  appearance — the  projections  and  depressions 
correspond  with  the  alveolar  cavities  and  the  septa  which 
separate  them  from  each  other. 

The  Posterior  Surface  has  a  bulging,  called  tuberosity, 
which  is  connected  to  the  palate  bones,  and  bounds  behind 
the  antrum — is  perforated  by  three  or  four  small  holes — the 
posterior  dental  canals  which  go  to  the  alveoli  of  the  molar 
teeth . 

The  Lower  Surface  extends  from  the  alveolar  processes  in 
front  to  the  horizontal  plate  of  the  palate  bones  behind,  call- 
ed the  palatine  processes,  which  are  rough  below,  forming 
the  roof  of  the  mouth,  and  smooth  above,  making  the  floor 
of  the  nostrils.  They  are  united  along  the  median  line,  at 
the  anterior  part  of  which  is  the  foramen  incisivum,  having 
two  openings  in  the  nares  above,  while  there  is  but  one  in 
the  mouth  below. 

The  Ui^per  or  Orhitar  Surface  is  triangular  in  shape,  with 
its  base  in  front  forming  the  anterior,  lower  and  internal 
edge  of  the  orbit — while  its  apex  extends  back  to  the  bot- 
tom, it  forms  the  floor  of  the  orbit  and  roof  of  the  antrum  ; 
its  internal  edge  is  united  to  the  lachrymal,  ethmoid,  and 
palate  bones  ;  its  external  edge  assists  in  forming  the  spheno- 
maxillary fissure,  and  along  its  central  surface  is  seen  a 
canal  running  from  behind,  forwards  and  inwards — the  in- 
fra-orbitar  canal.  This  canal  divides  into  two,  the  smaller 
is  the  anterior  dental,  which  descends  to  the  anterior  alveoli 
along  the  front  wall  of  the  antrum — the  other  is  the  proper 

ferior  turbinated  bone  ;  d  Inferior  meatus  of  nose  into  which  the  nasal  duct  opens  ; 
e  Nasal  process;  /Semilunar  notch  of  lachrymal  bone;  g  Nasal  spine;  h  h  Palate 
process ;  i  i  Alveolar  process ;  /  Palate  process  of  palate  bone ;  k  Palate  spine ; 
I  Tuberosity  of  palate  bone ;  m  llamular  process. 


34  ORGANS  OF  MASTICATION. 

continuation  of  the  canal  and  ends  at  tlie  infra-orbitar  hole  ; 
along  the  upper  part  of  the  line  uniting  the  palatine  pro- 
cesses there  is  a  ridge,  the  nasal  crest,  for  receiving  the  vo- 
mer, and  at  the  anterior  part  of  this  crest  there  is  a  projec- 
tion forwards,  the  nasal  spine ;  at  the  external  and  upper 
part  of  the  body  is  a  malar  process,  which  articulates  with 
the  malar  bone.  This  is  opposite  the  summit  of  the  maxil- 
lary sinus. 

The  body  of  the  superior  maxilla  is  occupied  by  a  large 
and  very  important  cavity  called  the  Antrum  Hicjhmorianum, 
or  Maxillary  Sinus.  This  cavity  is  somewhat  triangular  in 
shape_,  with  its  base  generally  looking  to  the  nose,  and  its 
apex  to  the  malar  process.  Its  upper  wall  is  formed  by  the 
floor  of  the  orbit,  its  lower  by  the  alveoli  of  the  molar  teeth, 
which  sometimes  perforate  this  cavity.  The  canine  fossa 
bounds  it  in  front,  while  the  tuberosity  closes  it  behind. 
But  the  shape  of  this  cavity  is  exceedingly  variable.  In  ex- 
amining a  collection  of  nearly  one  hundred  in  the  Mu- 
seum of  the  Baltimore  Dental  College,  no  two  were  found  to 
be  shaped  alike,  and  this  difference  is  as  marked  between  the 
right  and  the  left  in  the  same,  as  in  different  subjects.  The 
floor  of  some  is  nearly  flat,  but  in  the  majority  of  cases  it  is 
very  uneven,  sometimes  crossed  by  a  single  septum,  vary- 
ing from  one-eighth  to  half  an  inch  in  height,  at  other  times 
there  are  found  three  or  four  septa,  dividing  the  lower  part 
of  the  cavity  into  as  many  separate  compartments,  with  the 
bottom  or  floor  of  no  two  on  a  level  with  each  other.  Some 
are  perforated  by  the  roots  of  one  or  more  teeth  ;  at  other 
times  the  roots  of  several  teeth  extend  considerably  above 
the  level  of  the  floor  of  the  antrum  covered  by  a  lamina  of 
bone  not  thicker  than  bank  note  paper.  In  other  cases,  the 
floor  of  the  antrum  is  half  an  inch  above  the  extremities  of 
the  roots  of  the  teeth.  This  cavity  also  differs  as  much  in 
size  as  it  does  in  shape. 

The  opening  of  the  antrum  is,  on  its  nasal  portion  or  base, 
into  the  middle  meatus  of  the  nose,  and  in  the  skeleton  is 
large,  while  in  the  natural  state  it  is  much  contracted  by 


ORGANS  OF  MASTICATION.  35 

the  ethmoid  hone  ahove,  the  inferior  spongy  bone  helow,  the 
palate  bone  behind,  and  by  the  mucous  membrane  which 
passes  through  this  opening  and  lines  its  interior. 

This  antrum  communicates  with  the  anterior  ethmoidal 
cells  and  frontal  sinus. 

The  structure  of  the  upper  jaw  is  thick  and  cellular  in  its 
alveolar  and  other  processes. 

It  is  articulated  with  two  bones  of  the  cranium,  the  fron- 
tal and  ethmoid,  and  seven  of  the  face,  namely  :  the  nasal, 
malar,  lachrymal,  palate,  inferior  spongy,  vomer^  to  its  fel- 
low and  also  to  the  teeth. 

Its  development  is  very  complicated,  and  is  stated  to  be 
by  as  many  osseous  points  as  that  of  the  body  and  its  various 
processes.  Ossification  commences  at  a  very  early  period  of 
intra-uterine  existence.*  It  may  be  seen  as  early  as  the 
thirtieth  or  thirty-fifth  day  after  conception ;  and  although 
at  birth  it  has  acquired  but  little  height,  it  has  increased 
considerably  in  breadth.  But,  at  this  period,  the  alveolar 
border,  which  constitutes  the  largest  portion  of  the  bone,  is 
almost  in  contact  with  the  orbit.  The  antrum,  at  this  time, 
is  scarcely  perceptible,  but  as  the  vertical  dimensions  of  the 
bone  are  increased,  it  gradually  develops  itself.  With  the 
loss  of  the  teeth,  the  alveolar  border  nearly  disappears,  so 
that  the  vault  of  the  palate  loses  its  arched  form,  and  be- 
comes almost  flat. 

The  Lower  Jaio,  Fig.  5,  is  the  largest  bone  of  the  face, 
and  though  but  one  bone  in  the  adult,  it  consists  of  two 
symmetrical  pieces  in  the  fetus. 

It  occupies  the  lower  part  of  the  face — has  a  semicircular 
form,  and  extends  back  to  the  base  of  the  skull. 

It  is  divided  into  the  body  and  extremities. 

The  body  is  the  middle  and  horizontal  portion  ;  this  is 
divided  along  its  centre  by  a  ridge  called  the  symphysis, 
which  is  the  place  of  separation  in  the  infant  state ;  the  mid- 
dle portion  projects  at  its  inferior  part  into  an  eminence 

*  Some  anatomists  say,  that  it  is  at  first  divided  into  three  parts. 


36 


ORGANS   OF   MASTICATION. 


called  the  mental  process  or  chin  ;  on  eacli  side  of  which  is  a 
depression  for  the  muscles  of  the  lower  lip,  and  externally 


INFERIOR   MAXILLARY   BONE. 
Fig.  5. 


Fig.  G. 


OEGANS   OF   MASTICATION.  37 

to  tliese  depressions  are  two  foramini,  called  anterior  mental, 
for  transmitting  an  artery  and  nerve  of  the  same  name. 

The  horizontal  portion  or  sides  extends  backwards  and 
outwards  ;  and  on  the  outer  surface  has  an  oblique  line  for 
the  attachment  of  muscles. 

On  the  inner  surface  of  the  middle  part  behind  the  chin, 
along  the  line  of  the  symjDhysis,  there  is  a  chain  of  emi- 
nences called  genial  processes ;  to  the  superior  of  which  the 
frenum  linguee  is  attached,  to  the  middle  the  genio-hyo- 
glossi,  and  to  the  inferior  the  genio-hyoid  niuscles ;  on  each 
side  of  these  eminences  are  depressions  for  the  sublingual 
glands  ;  and  on  each  side  of  these  depressions  there  runs  an 
oblique  ridge  upwards  and  outwards,  to  the  anterior  part  of 
which  is  attached  the  mylo-hyoid  muscle,  and  to  the  posterior 
part,  the  superior  constrictor  of  the  pharynx  ;  this  latter 
muscle  is  consequently  involved  more  or  less  in  the  extrac- 
tion of  the  last  molar  tooth.  Below  this  line  there  is  a 
groove  for  the  mylo-hyoid  nerve. 

The  upper  edge  of  the  body  is  surmounted  by  the  alveolar 
processes  and  cavities,  corresponding  in  number  and  size  to 
the  roots  of  the  teeth.  (See  Fig.  6.)  The  alveolar  border, 
in  the  fetus,  constitutes  nearly  the  whole  of  the  body  of  the 
bone.  After  the  loss  of  the  teeth,  this  part  of  the  inferior 
maxillary  is  gradually  wasted.  The  alveolar  border,  in  the 
lower  jaw,  describes  a  rather  smaller  arch  than  it  does  in 
tlic  upper,  and  in  both  it  is  thinner  anteriorly  than  posteri- 
orly. 

The  lower  edge,  called  the  base,  is  rounded,  obtuse,  and 
receives  the  superficial  fascia  and  platysma  muscle. 

The  extremities  of  the  body  have  two  large  processes  ris- 
ing up  at  an  obtuse  angle,  named  the  rami  of  the  lower  jaw. 
These  processes  are  flat  and  broad  on  their  surfaces  ;  the 
outer  is  covered  by  the  masseter  muscle  ;  the  inner  has  a 


Fio.  5.  The  inferior  maxillary:  a  Body  of  the  bone ;  6  Mental  foramen  ;  c  The 
symphysis ;  d  d  Alveolar  processes  ;  e  Ramus  of  the  lower  jaw  ;  /  Its  angles  ;  g  g 
Coronoid  processes;  h  h  Sio;moid  notch  ;  i  i  Condyloid  processes;  jj  Xcck  of  the 
condyles  ;  k  Inferior  ductal  foramen  ;  I  Jlylo-hyoidean  ridge. 


38  ORGANS   OF   MASTICATION. 

deep  groove  which  leads  to  a  large  hole,  the  posterior  dental 
or  maxillary  foramen_,  for  transmitting  the  inferior  dental 
nerves  and  vessels  to  the  dental  canal  running  along  the 
roots  of  the  teeth.  This  foramen  is  protected  by  a  spine  to 
which  the  internal  lateral  ligament  is  attached. 

The  ramus  has  a  projection  at  its  lower  part  which  is  the 
angle  of  the  lower  jaw  ;  its  upper  ridge  is  curved,  having  a 
j)rocess  at  each  end — the  anterior  one  is  the  coronoid  process; 
this  is  triangular,  and  has  the  temporal  muscle  inserted  into 
it ;  the  posterior  is  the  condyloid,  and  articulates  with  the 
temporal  bone.  This  process  has  a  neck  for  the  insertion  of 
the  external  pterygoid  muscle. 

The  structure  of  the  inferior  maxilla  is  compact  exter- 
nally, cellular  within  and  traversed  in  the  greater  part  of 
its  extent  by  the  inferior  dental  canal. 

The  lower  jaw  is  developed  by  two  centres  of  ossification, 
which  meet  at  the  symphysis.  It  articulates  at  each  side  by 
one  of  its  condyles  with  the  glenoid  cavity  of  the  temporal 
bone,  situated  at  the  base  of  the  zygomatic  process.  This 
cavity  is  divided  into  two  portions — an  anterior  and  pos- 
terior. The  former  constitutes  the  articular  portion,  the 
latter  lodges  a  process  of  the  parotid  gland.  The  two  are 
separated  by  the  fissure  of  Glasserius,y?ssMrt  glasseri,  which 
transmits  the  chorda  tympani  nerve^  the  laxitor  tympani 
muscle  and  the  internal  auditory  vessel.  It  also  gives 
attachment  to  the  long  process^  processus  gracilis,  of  the 
malleus. 

Between  this  cavity  and  the  condyle,  there  is  interposed 
an  interarticular  cartilage,  so  moulded  as  to  fit  the  two  ar- 
ticular surfaces.  The  circumference  of  this  being  free, 
except  where  it  adheres  to  the  external  lateral  ligament  and 
afi'ords  attachment  to  a  few  fibres  of  the  external  pterygoid 
muscle,  facilitates  the  movements  of  the  joint. 

The  union  of  this  articulation  is  maintained  by  the  exter- 
nal and  internal  lateral,  and  the  stylo-maxillary  ligaments. 
The  external  lateral  is  seen  in  Fig.  32. 


ORGANS  OF  MASTICATION.  39 


THE  PALATE  BONES. 

The  palate  bones,  two  in  number,  and  in  pairs,  are  situa- 
ted at  the  back  part  of  the  superior  maxillary  bone^  between 
its  tuberosities  and  the  pterygoid  processes  of  the  sphenoid 
bone.     They  are  shaped  precisely  alike. 

The  palate  bone  is  divided  into  three  plates — the  horizon- 
tal or  j)alate,  the  vertical  or  nasal,  and  the  orbital. 

The  palate  plate  is  broad  and  on  the  same  line  with  the 
palate  j^rocesses  of  the  superior  maxillary  bone  ;  its  upper 
surface  is  smooth,  and  forms  the  posterior  floor  of  the  nos- 
trils— the  lower  surface  is  rough,  and  forms  the  posterior 
part  of  the  roof  of  the  mouth  ;  its  anterior  edge  is  connected 
to  the  palate  process  of  the  upper  jaw,  and  its  posterior  is 
thin  and  crescentic,  to  which  is  attached  the  velum-pendu- 
lum jDalati  or  soft  jjalate  ;  at  the  posterior  point  of  the 
suture,  uniting  the  two  palate  bones,  there  projects  back- 
wards a  process  called  the  posterior  nasal  spine,  which  gives 
origin  to  the  azygos-uvulte.  muscle.  The  vertical  plate  as- 
cends^ helps  to  form  the  n^^-  diminishes  the  opening  into 
the  antrum  by  projecting  forward,  and  by  its  external  pos- 
terior part,  in  conjunction  with  the  pterygoid  processes 
of  the  sphenoid  bone,  forms  the  posterior  palatine  canal ; 
the  lower  orifice  of  which  is  seen  on  the  margin  of  the 
palate  plate,  and  called  the  posterior  palatine  foramen, 
which  transmits  the  palatine  nerve  and  artery  to  the  soft 
palate  ;  behind  this  foramen  is  often  seen  a  smaller  one 
passing  through  the  base  of  the  pterygoid  process  of  this 
bone,  and  sending  a  filament  of  the  same  nerve  to  the  pal- 
ate. 

The  upper  end  of  the  vertical  or  nasal  plate  has  two  pro- 
cesses— the  one  is  seen  at  the  back  of  the  orbit,  called  the 
orbital  process ;  the  other  is  posterior  and  fits  to  the  under  sur- 
face of  the  body  of  the  sphenoid  bone.  Between  these  two 
processes  there  is  a  foramen,  the  spheno-palatine,  which 
transmits  to  the  nose  a  nerve  and  artery  of  the  same  name. 


40 


ORGANS  OF  MASTICATION. 


Fig.  8 


The  palate  bone  articulates  with  six  others,  namely  :  the 
superior  maxillary,  inferior  turbinated,  vomer,  sphenoid  and 
ethmoid. 

The  structure  of  this 
bone  is  very  thin,  and 
consists  almost  entirely 
of  compact  tissue.  Its 
development,  it  is  said, 
takes  place  by  a  single 
point  of  ossification  at 
the  place  of  the  union  of 
the  vertical,  horizontal 
and  pyramidal  portions. 
These  bones  are  all  more  or  less  related  with  the  bones  of 
the  head — of  which  eight  compose  the  cranium  and  fourteen 
the  face.  Those  of  the  cranium  are  one  frontal,  two  parie- 
tal, two  temporal,  one  occipital,  one  sphenoid  and  one  eth- 
moid. Those  of  the  face  are  six  pairs  and  two  single  bones  ; 
the  pairs  are  the  two  malars,  two  superior  maxillary,  two 
lachrymal,  two  nasal,  two  palatine  and  two  inferior  spongy. 
The  vomer  and  inferior  maxillary  are  the  two  single  bones. 


THE  TEETH. 

The  teeth  are  the  prime  organs  of  mastication — are  the 
hardest  portions  of  the  body,  and  occupy  the  alveolar  cavi- 


Fio.  7.  Posterior  view  of  the  palate  bone  in  its  natural  position,  except  that  it  ia 
turned  a  little  to  one  side  so  as  to  show  the  internal  surlace  of  its  perpendicular 
plate  :  a  Nasal  surface  of  horizontal  plate  ;  6  Nasal  surface  of  perpendicular  plate  ; 
c  kl  Pterygoid  process  or  tuberosity  ;  d  Broad  internal  border  of  horizontal  plate, 
which  articulates  with  same  border  of  opposite  bone;  /  Piocess  with  which  same 
one  of  opposite  bone  of  the  other  side  forms  the  nasal  spine;  g  Horizontal  ridge 
which  gives  attachment  to  inferior  turbinated  bone;  h  Spheno-palatine  foramen; 
i  orbital  portion  ;  j  Pterygoid  apophysis. 

FiQ.  8.  Spheno-maxillary  surface  of  perpendicular  plate  of  palate  bone :  a  Its 
rough  surface,  or  the  one  which  articulates  with  superior  maxillary  bone  ;  b  Part 
of  the  posterior  palatine  canal ;  c  Spheno-palatine  foramen;  d  Spheno-maxillary 
facet;  e  Orbital  facet ;  /  Maxillary  facet;  ^Sphenoidal  portion  of  perpendicular 
plate;  h  Tuberosity  of  the  base  or  pterygoid  process. 


ORGANS  or  MASTICATION. 


41 


ties  of  both  the  ujDper  and  lower  jaw.  F'^''-  ^^ 

Although  analogous  in  structure  to  bone^ 
they  are  regarded,  from  their  develop- 
ment, as  a  modification  of  mucous  mem- 
brane. 

A  tooth  is  composed  of  four  distinct 
substances:  1.  The  j92(7p,  occupying  the 
chamber  in  the  crown  and  canal  extend- 
ing through  the  root ;  2.  The  dentine, 
which  constitutes  the  principal  part  of 
the  organ  ;  3.  The  ewameZ,  which  forms 
the  covering  and  protection  of  the 
crown  ;  4.  The  cementum  or  crusta  j)&- 
trosa,  which  covers  the  root.  (See 
Fig.  9.) 

The  teeth  of  first  dentition,  termed 
the  milk,  temporary  or  deciduous  teeth, 
and  designed  to  supply  merely  the  wants 
of  childhood,  are  replaced  with  a  larger, 
stronger  and  more  numerous  set.  These 
are  termed  the  permament  or  adult  teeth,  and  are  intended 
to  continue  through  life. 

The  anatomical  divisions  of  a  tooth  are:  1.  The  crown 
or  exposed  part  situated  above  the  gum  ;  2.  The  root  oc- 
cupying the  alveolar  cavity  or  socket ;  3.  The  neck  which  is 
the  constricted  portion  between  the  crown  and  root. 


THE    TEMPORARY    TEETH. 

The  temporary  are  divided  into  three  classes  :  first,  the 
incisors  ;  second,  the  cuspidati ;  third,  the  molars,  which  are 
succeeded  by  the  biscuspidati. 


Fig.  9.   a  The  coronal  surface  divested  of  enamel ;  feThedentine;  cThecavityof 
the  pulp  J  d  The  cementum,  or  crusta  petrosa ;  e  The  enamel. 


42 


ORGANS  OF  MASTICATION. 
Fig.  10.  Fio.  II. 


I 


The  temporary  teetli  are  twenty  in  number,  ten  in  each 
jaw,  namely:  four  incisors,  two  cuspidati,  and  four  molars. 
*      The  pulp  cavity  of  a  temporary  tooth  is  larger  in  proix)r- 
tion  to  the  size  of  the  organ  than  in  a  permanent  tooth. ' 

THE    PERMANENT   TEETH. 

There  are  thirty-two  teeth  in  the  permanent  set,  sixteen 
to  each  jaw — being  an  increase  of  twelve,  over  the  tempo- 
rary, designated  as  follows  :  incisors,  four  ;  cuspids,  two  ; 
bicuspids,  four  ;  molars,  six  to  each  jaw.     The  third  or  last 

Fio.  10.  Front  view  of  the  temporary  teeth. 

Fig.  11.  Palatine  and  lingwal  Tiew  of  temporary  teeth. 

Fig.  12.  Lateral  or  side  view  of  temporary  teeth. 

FiQ.  13.  Temporary  teeth  split  so  as  to  expose  their  pulp  cavities. 


ORGANS  OF   MASTICATION. 


43 


molar  is  sometimes  designated  by  the  name  of  dens  sapien- 
tisB  or  wisdom  tooth. 


THE   PULP. 

The  pulp^  enclosed  in  the  centre  of  the  tooth,  is  the  first 
developed  part  of  the  organ,  and  the  part  from  which  the 
dentine  is  formed.  It  is  an  exquisitely  sensitive,  highly  vas- 
cular and  nervous  substance,  of  a  reddish-gray  color,  envel- 
oped in  an  exceedingly  delicate,  and  apparently,  structure- 
less membrane,  continuous  with  the  alveolo-dental  perios- 
teum and  adherent  to  the  walls  of  the  pulp  cavity.-  This  is 
designated  by  Mr.  Thomas  Bell  "the  proper  membrane  of 
the  pulp,"  and  by  Purkinje  and  Kaschkow,  "the  performa- 
tive membrane,"  because,  in  the  formation  of  the  dentine, 
the  deposition  of  earthy  salts  commences  in  it. 

Fig.  U.  Fiq.  15. 


Fig.  16. 


The  pulp,  according  to  the  two  last 
mentioned  authors,  is  composed  of  mi- 
nute globules.  Schwann  describes  it  as 
consisting  of  globular  nucleated  cells, 
with  vessels  and  nerves  passing  between 
them — the  cells  having  the  same  radial 
course  as  the  fibres  of  the  dentine.  Ac- 
cording to  the  microscopic  observations 

Fig.  14,  A  portion  of  the  body  of  the  pulp,  showing  the  cellular  arrangement. 

Fig.  16,  A  portion  of  a  superficial  layer  of  the  pulp,  showing  the  appearance  of 
vesicles. 

Fig.  16.  A  portion  of  the  body  of  the  pulp,  showing  another  variety  in  the  ar- 
rangement of  the  cells. 


44 


ORGANS  OF   MASTICATION. 


of  Mr.  Nasmyth,  it  is  principally  composed  of  minute  vesic- 
ular cells   varying  in  size  from  the  ten-thousandth  to  an 

'  Fig.  17. 


eighth  of  an  inch  in  diameter,  disposed  in  concentric  layers, 
whichj  when  mascerated,  have  an  irregular  reticular  appear- 

FiG.  17.  a  The  vessels  of  the  pulp  of  an  upper  central  incisor  injected,  as  seen 
under  the  microscope  bj  means  of  a  high  magnifying  power  ;  h  The  natural  size 
of  the  pulp. 


ORGANS  OF   MASTICATION. 


45 


ance,  and  are  found  to  be  interspersed  Avith  granules,  the 
parenchyma  being  traversed  by  vessels  having  a  vertical  di- 
rection. See  Figs.  14,  15  and  16,  copied  from  Mr.  Nas- 
myth's  Kesearches  on  the  Development  and  Structure  of  the 
Teeth. 

Mr.  Tomes  describes  it  as  consisting,  from  its  earliest  ap- 
jjearance,  of  a  series  of  nucleated  cells,  united  and  supported 
by  plasma,  and,  prior  to  the  commencement  of  the  formation 
of  the  dentine,  of  delicate  areolar  tissue,  occupied  by  a  thick, 
clear,  homogeneous  fluid  or  plasma.  The  pulp  is  liberally 
supplied  with  blood  vessels,  furnished  by  the  trunk  which 
enters  its  base.  The  ramifications  of  these  vessels  are  dis- 
tributed throughout  its  entire  substance,  forming  a  capillary 
net  work  which  terminates  in  loops  up\)n  its  surface. 

The  distribution  of  the  vessels  of  ^'o-  ^^• 

the  pulp  are  represented  in  Fig.  17, 
copied  from  the  late  work  of  Mr. 
Nasmyth,  and  made  from  an  in- 
jected preparation  of  an  upper  cen- 
tral incisor.  The  communication 
of  the  arteries  with  the  veins  by 
means  of  a  series  of  looped  capil- 
laries, presenting  a  densely  matted 
appearance  upon  the  surface,,  are 
here  beaiitifully  represented.  The 
nerves  of  the  pulp  have  a  very  sim- 
ilar arrangement  in  their  distribu- 
tion as  the  vessels,  having,  as  may 
be  seen  in  Fig.  18,  like  looped  ter- 
minations. 

Kulliker  describes  the  pulp  as 
consisting  of  an  indistinctly  fibrous 
connective  tissue,  containing  many 
dispersed,  rounded  and  elongated 
■nuclei,  with,  occasionally,  narrow 
bundles,   somewhat  like  imperfect 

Fig.  18.  The  nerves  of  the  pulp  of  an  upper  adult  bicuspis,  magnified  twenty 
diameters. 


CI 


46  ORGANS  OF  ilASnCAHON. 

fetal  connective  tissue,,  filled  with  a  fluid  substance.  Imme- 
diately beneath  the  structureless  membrane  in  which  these 
structures  are  inclosed,  there  is  a  layer,  composed  of  many 
series  of  cells,  cylindrical  or  pointed  at  one  end,  with  long 
narrow  nucleated  nuclei,  arranged  perpendicularly  to  the 
surface  of  the  pulp,  like  a  cylinder  of  epithelium.  This 
layer  is  described  as  being,  from  two  to  four  one-hundredths 
of  a  line  in  thickness.  These  regular  series,  proceeding  in- 
ternally, become  less  and  less  distinct,  ''but  the  cells,  with- 
out losing  their  radial  arrangement^  are  more  intermixed, 
and  pass,  finally,  by  shorter  and  rounder  cells,  without 
any  sharp  lines  of  demarkation,  into  the  vascular  tissue  of 
the  pulp. ' '  His  description  of  the  distribution  of  the  vessels 
and  nerves  of  the  pulp  is  similar  to  that  given  by  Mr. 
Nasmyth  and  Mr.  Tomes. 

The  pulp^  previous  to  the  formation  of  the  dentine,  is  in- 
closed in  a  sac,  consisting  of  two  laminre,  an  outer  and  in- 
ner. The  former,  is  described  by  Mr.  Hunter  as  being  soft 
and  spong}^,  and  without  vessels  ;  and  the  latter  to  be  ex- 
tremely vascular  and  firm.  Mr.  Thomas  Bell,  on  the  other 
hand,  contends  that  the  outer  is  full  of  vessels,  while  the 
inner  is  destitute  and  more  tender,  and  this  opinion  is  sup- 
ported by  the  microscopic  researches  of  Mr.  Nasmyth,  who 
describes  the  internal  lamina  of  the  capsule,  previous  to  its 
closing  and  forming  a  sac,  as  possessing  no  vessels,  though 
the  injections  of  Mr.  Fox,  would  seem  to  prove  the  contrary. 
But  as  the  author  will  again  have  occasion,  when  he  comes 
to  treat  of  the  origin  and  formation  of  the  teeth,  to  recur  to 
this  subject,  he  will  not  enlarge  upon  it  in  this  place. 

THE   DENTINE. 

The  dentine  (6  Fig.  9)  is  a  very  hard,  dense  substance, 
constituting  the  inner  and  large  portion  of  the  crown  and 
nearly  the  whole  of  the  root  of  the  tooth.  It  consists  of 
earthy  salts  and  animal  matter.  The  former  may  be  re- 
moved by  the  application  of  acid,  leaving  the  latter  entirely 


ORGANS  OF  MASTICATION. 


4Y 


separate,  and  by  applying  heat,  the  animal  portion  may  be 
destroyed,  leaving  the  earthy. 

FiQ.  19. 


B 

Dentine  is  harder  than  bone  or  cement-  ^^^-  '^^• 

um,  but  less  dense  than  enamel.  It  is  dis- 
posed in  concentric  layers,  arranged,  one 
within  the  other,  parallel  to  the  surface  of 
the  tooth — the  last  internal  layer  forming 
the  boundary  of  the  pulp-cavity.  But  in 
addition  to  this  peculiar  structural  arrange- 
ment, it  is,  according  to  the  microscpic  ob- 
servations of  Purkinje,  Ketzius  and  Mliller, 
composed  of  minute  tubes  or  hollow  fibres, 
radiating  from  the  pulp  cavity  to  the  periphery  of  the  tooth, 
giving  off,  in  their  course,  numerous  branches,  as  seen  in 
Fig.  19,  sometimes  terminating  in  small  cells  or  corpuscles, 
and  an  amorphous  or  structureless  intertubular  substance. 
The  doctrine  of  the  tubularity  of  dentine  is  also  sustained 
by  the  subsequent  researches  of  Professor  Owen,  Mr.  Tomes, 
Kulliker  and  several  other  microscopists  ;  while  on  the  other 

Fig.  19.  Dentine  and  cement  from  the  root  of  a  human  incisor  tooth,  copied  from 
Kcilliker  :  a  Dentinal  fibres  or  tubes  ;  h  Interglobular  spaces,  having  the  appear- 
ance of  the  iacunce  in  bone  ;  c  Smaller  interglobular  spaces;  <Z  Commencement  of  the 
cement,  with  numerous  canals  close  together  ;  e  Its  lamellce  ;  f  Lacun<K  ;  g  Canals. 

Fig.  20.  Transverse  section  through  the  dental  tubuli  of  the  root  of  a  human 
tooth,  magnified  360  diameters,  showing  their  numerous  anastomoses. 


48  ORGANS  OF  MASTICATION. 

hand,  Mr.  Alexander  Nasmytlij  equally  distinguished  as  an 
odontologist,  has  seeminglj^  demonstrated  hy  a  series  of 
beautiful  and  highly  interesting  experiments,  that  the  ca- 
naliculi  or  tubes  of  these  gentlemen,  are  solid  fibres  ''com- 
posed of  a  series  of  little  masses,  succeedirrg  each  other  in  a 
linear  direction,  like  so  many  beads  collected  on  a  string," 
See  Fig.  21. 

Fig-  21.  The  tubes  radiate  from  the  pulp 

cavity  to  the  outer  surface  of  the  den- 
tine, each  tube  making  three  princi- 
pal or  primary  curves  in  its  course, 
and  presenting,  when  examined  with 
a  high  magnifying  power,  numerous 
secondary  undulations,  which  are  less 
l)erceptible  at  the  external  extremity 
of  the  tubes  than  the  middle,  and 
still  less  in  the  temporary  than  in 
the  permanent  teeth.  The  diameter  of  the  tubes,  from 
their  commencement  to  the  middle  of  the  outer  third  of  their 
courses  is  estimated  at  ^jy  of  a  French  line,  but  from 
this  point  their  terminal  branches  rapidly  diminish  until 
they  become  invisible,  or  are  lost  in  small  irregular  rounded 
cells.  When  examined  under  a  magnifying  power  of  from 
three  to  five  hundred  diameters,  tliey  are  seen  to  branch  by 
a  dichotomatous  division  and  in  their  whole  course  to  give 
off  numerous  lateral  branches.  The  tubes  are  not  mere  ex- 
cavations, but  have  special  parietes,  the  undulations  in 
them  are  ascribed  to  certain  periodic  movements  in  the  pulp 
during  the  formation  of  the  successive  layers  of  dentine^  and 
both  Retzius  and  Miiller  represent  them  as  containing  gran- 
ular masses  of  inorganic  matter.* 

Fig.  21.    The  nuclei  of  fibres  of  dentine,  arranged  in  a  linear  series,  as  shown  bv 
Mr.  Nasmvth. 

*  MUller'a  Physiology. 


I 


ORGANS  OF  MASTICATION.  49 

These  tubes  are  represented  as  pierc- 
ing every  part  of  the  surface  of  the  pulp 
cavity,  and  according  to  Professor  Owen, 
are  about  the  is^^s  part  of  an  inch  in 
diameter ;  they  radiate  as  before  stated, 
from  the  inner  to  the  peripheral  surface 
of  the  dentine,  ''In  the  lower  incisor 
and  canine  teeth,"  says  the  last  mentioned  author^  "those 
from  the  middle  of  the  summit  of  the  pulp  cavity,  ascend 
vertically  to  the  enamel  covered  surface  of  the  dentine  at  the 
summit  of  the  crown  ;  the  tubes  on  each  side  of  these  grad- 
ually incline  outwards  ;  those  which  go  to  the  angles  of  the 
crown,  forming  an  angle  of  45°  with  the  middle  vertical 
tubes  ;  at  the  sides  of  the  crown  the  tubes  incline  still  more 
outwards,  until  in  the  middle  of  the  fang  they  become  hori- 
zontal, and  still  lower,  bend  downwards."*  The  vertical 
tubes  are  described  as  being  nearly  straight,  but  as  they 
begin  to  incline  downwards,  they  present  two,  and  usually 
three  curves  ;  at  the  sides  of  the  crown  and  the  upper  half 
of  the  root  they  have  a  short  concave  bend  towards  the 
crown,  then  a  longer  curve  in  the  opposite,  and  finally  a 
third  curve  in  the  first  direction,  but  having  a  general  con- 
cave bend  downwards.  The  course  of  the  tubuli,  however, 
may  be  seen  in  Fig.  9. 

The  secondary  curvatures  of  the  dentinal  fibres,  or  tubes, 
are  very  numerous  ;  the  last  mentioned  author  says,  "two 
hundred  may  be  counted  in  an  extent  of  yV  of  ^^  inch  ;  the 
curvatures  observed  in  these,  both  primary  and  secondary, 
are  parallel.  Professor  Ketzius  describes  certain  striaj,  run.- 
ning  parallel  with  the  pulp  cavity_,  '"like  the  annual  rings 
in  the  trunk  of  a  tree."  These  circular  lines  are  rarely 
seen  in  dentine  of  human  teeth,  though  very  observable  in 

Fig.  22.     A  section  of  dentine  made  transversely  across  the  tubuli  showing  the 
opening  into  the  tubes  and  their  parietes,  copied  from  Muller's  Physiology. 

*  Owen's  Odontography. 


r 


50  ORGANS  OF  MASTICATION. 

some  animals,  especially  tlie  elephant,  and  they  are  some- 
what similar  to  the  contour  lines  of  Professor  Owen,  pro- 
ceeding from  '^a  short  bend,"  occasionally  observed  in  the 
tubes,  '^along  a  line  parallel  with  the  crown." 

The  dentinal  fibres  of  the  crown,  in  the  teeth  of  the 
human  subject,  give  off  but  few  branches^  until  they  arrive 
nearly  to  the  outer  surface  of  the  dentine  ;  the  ramifications 
become  more  and  more  numerous  towards  the  extremity  of 
the  root,  and  here,  too,  the  terminal  branches  anastomose^ 
more  frequently  with  each  other.  In  the  crown  they  some- 
times pass  a  short  distance  into  the  enamel,  or  terminate  in 
small  cavities  near  the  surface,  and  it  is  here,  or  imme- 
diately upon  the  peripheral  surface  that  dentine  is  most 
sensitive. 

The  researches  of  Mr.  Nasmyth  into  the  structure  of  den- 
tine, as  already  intimated,  do  not  accord  with  those  of  most 
other  microscopists  ;  he  found,  when  sections  made  parallel 
to  the  fibres  were  submitted  to  the  action  of  acid  until  the 
earthy  salts  were  all  taken  up  that  the  animal  residue  con- 
sisted of  solid  fibres,  presenting  an  irregular  or  baccated 
appearance,,  being  composed  of  numerous  separate  compart- 
ments or  cells,  corresponding  exactly  with  the  reticulations 
observed  on  the  surface  of  the  pulp,  previous  to  the  deposition 
of  earthy  salts,  see  Fig.  21.  The  shape  and  size  of  these 
cells,  he  describes  as  varying  in  difierent  animals  ;  in  the 
human  tooth  as  being  oval,  and  as  having  their  long  axis 
corresponding  with  the  course  of  the  fibre,  and  the  extremity 
of  each  in  apposition  to  the  one  adjoining.  The  result  of 
Mr.  Nasmyth' s  investigations,  it  must  be  confessed,  appears 
to  justify  the  conclusion  at  which  he  has  arrived  in  relation 
to  this  matter,  but  whether  correct  or  erroneous,  the  author 
will  not  at  present  attempt  to  decide. 

The  interfibrous  tissue  constitutes  a  larger  portion  of  the 
dentine  in  the  root  than  in  the  crown  of  the  tooth,  and  is 
supposed,  by  Purkinje,  Ketzius^  Miiller,  Kolliker,  and  oth- 
er equally  distinguished  microscopists,  to  be  structureless. 
Professor  Owen  and  Mr.  Nasmyth,  describe  it  as  cellular 


ORGANS  OF   MASTICATION.  51 

Mr.  Tomes  says,  '''it  is  made  up  of  minute  granules,  closely 
united."     Professor  Kolliker,  calls  it  the  matrix  of  the  ca- 
nals,   or   tubules,  and  affirms  that  it   is   "homogeneous," 
"without  cells,  fibres  or  other  elements."     The  cells  of  Mr, 
Nasmyth  and  Professor  Owen,  are  sujDposed  by  some  to  be 
nothing  more  than  miergranular,  or  as  they  are  designated 
by  Czermak,  interglobular  spaces,  and  to  consist  of  very 
minute  irregular  cavities  :  these  spaces  are  observed  more 
frequently  in  the  crown  near  the  enamel,  where  they  seem 
to  be  composed  of  numerous  thin  layers,  into  which  the  con- 
tour lines,  or  as  Salter  calls  them,  contour-markings,  enter. 
They  are  also  described  as  being  seen  more  internally  near  the 
pulp  cavity  and  as  being  frequently  pierced  by  the  tubuli. 
The  smaller  spaces,  from  their  communication  with  the  tu- 
bules,have  beenregarded  by  some  as  identical  with  the  lacunce 
of  bone.     But  Professor  Kolliker  states  that  he  has  rarely 
"observed  actual  lacunce  in  normal  dentine,"  and  when  pres- 
ent they  were  always  at  the  boundary  of  the  cement,  but '  'in- 
terglobular spaces  and  dentinal  globules"  are  met  with  in 
the  interior  of  the  root  and  on  the  walls  of  the  pulp  cavity, 
in  which  latter  place  they  give  rise  to  irregularities  which 
may   be   seen   with   the  naked   eye.     Again,  he  observes, 
"the   interglobular   spaces   whose   presence   is    normal   in 
developing  teeth,  contain,  during  life,  not  fluid,  as  might 
at  first  be  expected,  but  a  soft  substance  resembling  tooth 
cartilage  and  possessing  a  canaliculated  structure,  like  the 
dentine  itself.     It  is  remarkable  that  this  substance  offers  a 
greater  resistance  to  long  masceration  in  hydrochloric  acid 
than  the  matrix  of  the  actually  ossified  tooth,  and,  there- 
fore, like  the  dentinal  canals,  it  may  be  completely  isolated. 
In  sections,  this  interglohular  substance  usually  dries  up  in 
such  a  manner  that  a  cavity  is  produced,  into  which  air 
penetrates."     It  is  these,  according  to  this  author,  which 
constitute  the  interglobular  spaces,  but  there  are  many  teeth 
in  which  this   interglobular  substance  cannot  be  detected, 
where  delicate  arched  outlines  of  dentinal  globules  may  be 
observed.     Each  of  these  granules,  if,   indeed,  the  interfi- 


52  ORGANS  OF  MASTICATION. 

brous  tissue  is  made  up  in  them,  is  euclosed  in  a  delicate 
investment  of  animal  matter,  upon  wliicli  exceedingly  mi- 
nute vessels  arc^  no  doubt,  distributed. 

Mr.  Tomes  describes  a  granular  layer  upon  the  surface  of 
the  root  where  the  canals  have  become  very  small,  in  which, 
from  the  absence  of  the  uniting  medium  of  the  granules,  (the 
interglobular  substance  described  by  Professor  Kulliker,) 
these  spaces  occur.  He  also  states,  that  many  of  the  termi- 
nal tubes  communicates  with  these  granular  cells,  as  do  oth- 
ers, which  come  from  the  cells  of  the  cementum.  The  cells 
according  to  this  author,  frequently  communicate  with  each 
other,  though  there  does  not  appear  to  be  any  special  pro- 
vision for  such  communication. 

Dentine  is  regarded  by  most  microscopists^  especially  of 
human  teeth,  as  destitute  of  vascular  canals,  but  the  author 
has  seen  ten  or  twelve  specimens  in  which  their  existence 
was  so  clearly  demonstrated  as  to  leave  no  room  for  doubt. 
A  description  and  drawing  of  one  of  which  he  published  in 
the  second  volume  of  the  American  Journal  of  Dental 
Science.  A  similar  one  was  shown  to  him  by  Dr.  May- 
nard,  of  Washington  City,  and  he  has  a  section  of  a  molar 
tooth  made  by  Dr.  Blandy,  in  which  several  vessels  charged 
with  red  blood  are  distinctly  seen.  Mr.  Tomes  says  he  has 
seen  eight  or  ten  sections  of  vascular  dentine,  and  he  has 
given  a  drawing  of  one  in  which  the  dentine  and  cementum 
are  both  pierced  by  vascular  canals. 

Now,  if  vessels  have  been  detected  in  dentine  in  so  many 
instances,  it  seems  more  than  probable  that  they  are  always 
present,  though  too  small  and  attenuate  to  convey  any  thing 
but  tlie  thinnest  and  most  serous  part  of  the  blood. 

The  delicate  sensibility  of  dentine,  especially  when  in  a 
pathological  condition,  seems  also  to  favor  the  opinion  that 
nerve  filaments  are  sent  from  the  pulp  to  every  part  of  this 
tissue,  traversing,  no  doubt,  the  tubuli,  which  extend  from 
the  central  chamber  to  the  periphery.  Believing  dentine  to 
be  supplied  with  such  filaments,  Dr.  Maynard  stated  to  the 
author,  several  years  ago,  that,  in  removing  diseased  dentine 


ORGANS  OF   MASTICATION. 


53 


preparatory  to  filling,  especially  from  the  side  of  a  tootli 
lie  found  that  liis  patient  experienced  much  less  pain  when 
he  applied  the  excavator  to  the  part  nearest  the  root  and 
cut  towards  the  coronal  extremity,  than  when  removed  in 
the  opposite  direction.  The  microscopical  researches  of 
Professor  Johnston  of  the  Baltimore  Dental  College,  seems 
also  to  demonstrate  the  fact  that  nerve  filaments  constitute 
an  essential  element  of  dentine.* 

The  surface  of  the  dentine  of  the  crown  of  a  tooth,  is,  as 
stated  by  Professor  Owen,  marked  by  numerous  pits,  cor- 
responding with  the  internal  extremities  of  the  enamel 
fibres,  and  into  which  they  are  received. 

Every  100  parts  of  dentine,  according  to  Berzelius,  con- 
tains, 

62. 


Fluate  of  lime^ 

2. 

Carbonate  of  lime. 

,         , 

5. 

5 

Phosphate  of  magnesia, 

1 

Soda  and  muriate  of  soda,    . 

1 

5 

Gelatine  and  water, 

• 

28. 
100. 

- 

Von  Bibra,  makes  dried  dentine  to  contain — 

Molar  of  a 

Molar  of 

Incisor  of  the 

woman  of  25. 

a  man. 

same  man. 

Pho.sphate  of  lime,  with  some 

fluoride  of  calcium. 

67.54 

66.72 

Carbonate  of  lime. 

7.97 

3.36 

Phosphate  of  magnesia. 

2.49 

1.08 

Salts, 

1.00 

0.83 

Cartilage,        .... 

20.42 

27.61 

Fat, 

0.58 

0.40 

100.00 

100.00 

Organic  substance. 

.     21.00 

28.01 

28.70 

Inorganic  substance. 

.     79.00 

71.99 

71.30 

*Am.  Jour.  Dent.  Sci.,  July  No.,  1857,  pp.  348. 


54  ORGANS  OF  MASTICATION. 

The  relative  proportions,  however,  of  the  organic  and  in- 
organic matter  are  not  always  the  same.  They  vary  accord- 
ing to  the  density  of  the  tooth. 

The  laminated  decomposition  which  occurs  in  caries  of  the 
teeth  is  owing  to  the  concentric  arrangement  of  the  dentine, 
or,  according  to  Mr.  Nasmyth^  of  the  cells. 

THE    ENAMEL. 

The  Enamel  (c  Fig.  9)  covers  the  crown,  and  extends  to 
the  neck  of  the  tooth,  but  terminating  sooner  upon  the  ap- 
proximal,  than  upon  either  of  the  other  surfaces.  It  is  the 
hardest  of  all  animal  substances,  is  pearly  white,  or  slightly 
tinged  with  yellow,  according  to  the  texture  of  the  tooth. 
Like  the  dentine,  it  varies  in  density,  being  harder  on  some 
teeth  than  others.  It  is  thickest  in  those  parts  of  the  teeth 
most  exposed  to  friction,  as  on  the  eminences  of  the  molars 
and  bicuspids,  and  the  cutting  edges  of  the  incisors  and 
points  of  the  cuspids,  gradually  diminishing  to  the  line  of 
its  termination.  The  structure  of  the  enamel^  according  to 
Mr.  Nasmyth,  is  Jibro  cellular — the  fibres  radiating  from  the 
dentine  to  the  surface  of  the  tooth — an  arrangement  which 
gives  to  this  outer  investment  immense  strength  and  the 
power  of  sustaining  great  pressure.  It  has  a  smooth  glossy 
surface,  and  on  the  permanent  teeth^  is  characterized  by  del- 
icate circular  ridges  and  furrows,  which,  as  stated  by  Czer- 
mak,  are  never  seen  on  the  temporary  teeth.  It  is  covered 
by  a  delicate  ossified  membrane,  called  by  Professor  KOlli- 
ker,  the  cuticle  of  the  enamel,  and  by  Huxley,  Nasmyth's 
membrane,  because  Mr.  Nasmyth  was  the  discoverer  of  it. 
He  terms  it  the  ^ ^persistent  dental  capsule,"  and  says  it  is 
continuous  with  the  structure  covering  the  root.  It  is  similar 
to  the  membrane  between  the  internal  surface  of  the  enamel 
and  dentine,  which  constitutes  the  bond  of  union  between 
the  two.  This  membrane,  according  to  Professor  KoUiker, 
forms,  from  the  great  resistance  it  ofiers  to  chemical  reagents, 
a  peculiarly  appropriate  defence  for  the  crown  of  the  tooth. 


1 


ORGANS  OF   MASTICATION. 
Fig.  23.  FiQ.  25. 


55 


The  enamel  is  composed  of 
prisms  or  fibres,  for  the  most 
part  of  an  hexagonal  or  pentag- 
onal sha[)e,  arranged  side  by 
side  with  one  extremity  resting 
upon  the  dentine,  or  rather,  upon  the  intermedim^y  mem- 
brane, and  the  other  upon  Nasmyth's  membrane,  which, 
properly,  constitutes  the  peripheral  surface  of  the  crown  of 
the  tooth.  The  fibres  are  marked,  as  seen  in  fig.  24  by 
transverse  strife,  showing  them  to  be,  as  is  remarked  by 
Professor  Owen,  ''essentially  the  contents  of  extremely  deli- 
cate membranous  tubes,  originally  subdivided  into  minute 
depressed  compartments  or  cells,"  and  which,  the  author  is 
inclined  to  believe  constitutes  the  animal  frame-work  of  the 
tissue,  and  probably,  the  bond  of  union  between  the  fibres. 
The  existence,  however,  of  such  uniting  medium  is  not  gen- 
erally recognized  by  physiologists. 

The  prisms  of  the  enamel  have  a  wavy  course,  like  the 
dentinal  fibres  of  the  crown  of  the  tooth,  the  curvatures,  for 
the  most  part,  being  parallel  to  each  other,  and  more  mark- 

FiG.  23.  The  hexagonal  terminations  of  the  fibres  of  a  portion  of  the  surface  of 
the  enamel,  highly  magnified.  At  1,  2,  3,  the  crooked  crevices,  between  the  hex- 
agonal fibres,  are  more  strongly  marked. 

Fig.  24.  A  side  view  of  the  enamel  fibres  magnified  350  diameters  ;  1  1,  The  en- 
amel fibres;  2  2,  transverse  striae  upon  them. 

Fig.  25.  The  enamel  seen  on  the  face  of  a  vertical  section  showing  its  cellular 
structure. 


56 


ORGANS  OF   MASTICATION. 


eel  near  tlie  external  than  the  internal  surface.  The  curves, 
however,  in  the  enamel  fibres  are  shorter  and  more  strongly 
marked  than  in  the  dental  fibres.  The  prisms  usually  ex- 
tend through  the  entire  thickness  of  the  enamel,  but  some- 
times they  fall  short,  and  at  other  times  they  diverge  near 
the  external  surface.  When  either  of  these  happens, 
"shorter  complimental  fibres  fill  up  the  interspace." 

But  in  addition  to  the  peculiar  structural  arrangement 
just  described,  the  enamel,  according  to  Mr.  Nasmyth,  is 
cellular.  Each  cell,  as  may  be  seen  in  Fig.  25,  is  of  a  semi- 
circular form,  the  convexity  of  the  semicircle  looking  up- 
wards towards  the  free  external  portion  of  the  tooth. 

Thus,  by  this  most  beautiful  and  peculiar  structural  ar- 
rangement, a  capability  of  resisting  mechanical  force  is  giv- 
en to  the  enamel,  which  its  simple  fibrous  structure  would 
wholly  fail  to  supply. 

The  enamel,  like  the  dentine,  consists  of  organic  and  in- 
organic matter — the  former  being  less  than  the  latter.  Its 
chemical  composition,  according  to  Berzelius,  is^ 

85.3 


Fluate  of  lime, 

3.2 

Carbonate  of  lime,     . 

8. 

Phosphate  of  magnesia,     . 
Soda  and  muriate  of  soda. 

1.5 
1. 

Animal  matter  and  water, 

1. 

Von  Bibra  makes  it  to  consist  of 

100. 

From  s 
woman  21 

Phosphate  of  lime,  with  some 
fluoride  of  calcium. 

I  molar  of  a          From  a  molar 
)  years  of  age.    of  an  adult  man 

81.63                89.82 

Carbonate  of  lime. 

8.88 

4.37 

Phosphate  of  magnesia, 

Salts, 

2.55 
0.97 

1.34 

0.88 

Cartilage,           .... 

5.97 

3.39 

Fat, 

a  trace. 

0.20 

100.00 


100.00 


ORGANS  OF  MASTICATION.  57 

Organic  matters,        .         .         .5.97  3.59 

Inorganic  matters,     .         .         .94.03  96.51 

These  proportions,  as  in  tlie  case  of  dentine,  are  not 
always  the  same.  They  vary  in  the  enamel  of  the  teeth  of 
different  individuals. . 

THE   CEMENTUM. 

The  Cementum,  or  Criista  Petrosa,  (d  Fig.  9,)  covers  the 
root,  commencing  where  the  enamel  terminates,  gradually 
increases  in  thickness  to  its  apex.  It  has  also  been  traced 
over  the  enamel,  and  Mr.  Nasmy th^  is  of  the  opinion  that  it 
always  invests  the  crowns  of  the  teeth,  hut  the  author  has 
never  been  able  to  detect  it  except  upon  the  roots.  If,  there- 
fore, it  is  formed  upon  the  crown  it  is  evidently  soon  worn 
off  by  the  friction  of  mastication.  The  case  mentioned  by 
Purkinje  and  Frankel,  in  which  they  discovered  it  upon  the 
enamel  of  the  teeth  of  an  old  man,  is  an  exception  to  the 
general  rule. 

In  many  animals,  however,  it  covers  the  crowns  of  the 
teeth,  and  sometimes  unites  vertical  plates  of  enamel,  into  a 
solid  tooth,  as  in  the  case  of  the  molar  teeth  of  the  elephant. 

Cementum  corresponds  in  structure  with  the  osseous  tis- 
sue, being  furnished  with  lacunas^  and^  when  of  sufficient 
thickness,  is  traversed  by  vessels  capable  of  conveying  red 
blood.  Mr.  Tomes  says,  he  has  several  specimens  of  healthy 
human  teeth,  in  the  cementum  of  which  vascular  canals  ex- 
ist, and  in  one,  where  two  canals  enter  from  the  surface,  an- 
astomose, and  give  off  three  branches. 

The  cement,  like  dentine  is  arranged  in  concentric  layers. 
It  is  also  cellular — the  cells,  according  to  Mr.  Tomes,  being 
scattered  through  it  '"'with  some  degree  of  regularity,  gene- 
rally, though  not  always,  following  a  course  as  though 
placed  between  concentric  lamina3."  From  the  cells,  tubes 
are  given  off  which  anastomose  with  each  other  and  with 
those  from  contiguous  cells.  "By  this  arrangement,"  says 
5 


58 


ORGANS  OF  MASTICATION. 


the  author  last  named,  "a,  net-work  of  cells  and  tubes,  per- 
meable by  fluids,  is  carried  through  the  whole  mass."  He 
also  states  that  "the  majority  of  the  radiating  tubes  pass, 
either  towards  the  surface  of  the  tooth,  or,  when  such  ex- 
ists, towards  the  surface  of  a  canal  for  a  blood  vessel.  Many- 
branches  also  go  towards  the  dentine,  and  anastomose  with 
the  terminal  branches  of  the  dentinal  tubes,  while  a  few  fol- 
low the  course  of  the  length  of  the  tooth,  anastomosing  free- 
ly with  tubes  jiursuiug  a  like  direction.  Frequently,  how- 
ever, a  cell  with  its  tubuli  resembles  a  tuft  of  moss,  tlie  tubes 
taking  in  a  mass  one  direction  only,  and  that  towards  a  sur- 
face upon  which  blood  vessels  j)ass."  The  cells  of  the  ce- 
ment are  usually  oblong,  as  may  be  seen  in  Fig.  19,  though 
sometimes  they  are  circular  and  occasionally  fusiform .  They 
are  as  variable  in  size  as  in  shape.  The  average  of  their 
long  diameter  is  stated  by  Professor  Owen  to  be  about  j^^th 
of  an  inch. 

The  cement  is  much  thicker  on  the  permanent  teeth  than 
on  the  temporary,  and  it  is  thicker  on  the  teeth  of  old  per- 
sons than  on  those  of  young.  In  the  former  case  it  is  often 
reflected  into  the  pulp  cavity  at  the  extremity  of  the  root, 
sometimes  completely  obliterating  it  at  this  point. 

Cementum  is  composed,  according  to  Von  Bibra, 

In  man.  In  the  ox. 

Organic  matters,         .         .     29.42         32.24 
Inorganic  matters,      .         .     70.58         67.76 


100.00 

100.00 

In  the  latter  he  found  : 

Pho.si^hate  of  lime  and  fluoride  of  calcium,     58.73 

Carbonate  of  lime,     .... 

.       7.22 

Phosphate  of  magnesia,     . 

.       0.99 

Salts, 

.       0.82 

Cartilage,          ..... 

.    31.31 

Fat, 

.       0.93 

100.00 


ORGANS   OF  MASTICATION. 


59 


Thus  it  is  seen,  that  the  cementum  contains  a  larger  pro- 
portion of  organic  matters  than  dentine,  and  hence,  it  is  en- 
dowed with  greater  sensibility.  This  circumstance  will  ac- 
count for  the  fact  that,  when  the  neck  of  a  tooth  becomes  ex- 
posed by  the  recession  of  the  gums,  the  slightest  touch  is  of- 
ten productive  of  severe  pain.  Still  it  is  necessary  to  the 
preservation  of  the  connection  between  the  teeth  and  the  gen- 
eral system,  for  if  the  dentine  of  the  roots  were  not  covered 
by  it,  these  organs  would  act  as  irritants,  and  nature  would 
at  once  make  an  effort  to  expel  them  from  the  body.  In 
this,  therefore,  as  in  every  thing  else  connected  with  the 
animal  economy,  wisdom  of  design  is  displayed. 

DESCRIPTION  OF  TEETH  BKLONGING  TO  EACH  CLASS. 

Each  tooth,  as  has  already  been  remarked,  has  a  body  or 
crown,  neck  and  root.  In  describing  these  several  parts,  I 
shall  begin  with 

THE   INCISORS. 

The  Incisors  (four  to  each  jaw,  Fig.  26,  a  a,  a  a,)  occupy 
the  anterior  central  part  of  each  maxillary  arch.     The  body 

Fig.  26. 


Fig.  26.  aa,  aa  Front  view  of  the  incisors;  6  6,  6  6  Palatine  and  lingual  view ; 
c  c,  c  c  Side  or  lateral  view. 


60  ORGANS  OF  MASTICATION. 

of  eacli  is  wedge  shape — the  anterior  or  labial  surface  is  con- 
vex and  smooth^ — the  posterior  or  palatine  is  concave,  and 
presents  a  tubercle  near  the  neck  ;  the  palatine  and  labial 
surface  come  together,  and  form  a  cutting  edge.  In  a  front 
view,  the  edge  is,  generally,  the  widest  part;  it  diminishes 
towards  the  neck,  and  continues  narrowing  to  the  extremity 
of  the  root. 

The  crown  of  an  incisor  has  four  surfaces,  two  approxi- 
mal,  one  labial,  and  one  palatine  or  lingual  surface,  the  for- 
mer being  ajDplied  to  an  upper  and  the  latter  to  a  lower 
incisor.  It  also  has  four  angles,  namely,  a  rigid  and  a  left 
lahio-approximal,  and  a  right  and  a  left  palato-approximcd 
or  lingua-approximal. 

The  two  large  incisors  which  are  situated  one  on  each 
side  of  the  median  line,  are  termed  the  central  ;  the  other 
two,  the  lateral  incisors,  or  laterals.  The  crowns  of  the 
upper  central  incisors  are  about  four  lines  in  breadth,  and 
the  laterals  three.  In  the  lower  jaw,  the  crowns  of  the  cen- 
tral incisors  are  only  about  two  lines  and  a  half  in  width, 
while  the  laterals  are  usually  a  little  wider.  But  the  width 
of  the  crowns  of  all  the  incisors  varies  in  different  individ- 
uals. 

The  length  of  a  superior  central  incisor  is  usually  about 
one  inch,  and  that  of  a  lateral  eleven  lines  and  a  half.  In 
the  lower  jaw  the  central  incisors  are  only  about  ten  lines 
in  length  ;  the  laterals  are  about  one  line  and  a  half  longer. 

The  length  of  the  crown  of  an  incisor  is  exceedingly 
variable.  That  of  an  upper  central  varies  from  four  and  a 
half  to  six  lines,  and  there  is  the  same  want  of  uniformity 
in  this  respect  with  all  the  rest. 

The  roots  are  all  single,  of  a  conical  form,  flattened 
laterally,  and  slightly  furrowed  longitudinally  The  en- 
amel is  thicker  before  than  behind,  and  behind  than  at  the 
sides. 

The  function  of  this  class  of  teeth,  as  their  names  import, 
is  to  cut  the  food,  and  for  the  performance  of  this  office  they 
are  admirably  fitted  by  their  shape.  As  age  advances,  their 
edges  often  become  blunted,  but  the  rapidity  with  which 


ORGANS  OF  MASTICATION. 


61 


they  are  worn  away,  depends  altogether  upon  the  manner 
in  which  those  of  the  upper  and  lower  jaw  come  together. 


THE   CUSPID  ATI. 

The  Cuspidafi,  or  Canini,  (Fig.  27,)  are  situated  next  to 
the  incisors,  and  are  two  to  each  jaw — one  on  either  side. 
They  somewhat  resemble  the  upper  central  incisors  with 
their  angles  rounded.  Their  crowns  are  conical,  very  con- 
vex externally,  and  their  palatine  surface  niore  uneven,  and 
having  a  larger  tubercle  than  the  incisors.  Their  roots  are 
also  larger,  and  the  longest  of  all  the  teeth,  and  like  the 
incisors,  are  also  single,  but  have  a  groove  extending  from 
the  neck  to  the  extremity,  showing  a  step  at  forming  two 
roots.  A  cuspidatus,  like  an  incisor,  has  four  surfaces,  and 
four  angles,  designated  by  the  names  already  given. 

The  breadth  of  the  crown  of  an  upper 
cuspidatus  is  about  four  lines — that  of  a 
lower  is  about  three  and  a  half ;  but  as 
in  the  case  of  the  incisors,  the  width  of 
the  crowns  of  these  teeth  is  variable. 
The  length  of  a  cuspidatus  is  greater 
than  that  of  any  other  tooth  in  the  den- 
tal series — it  being  about  thirteen  lines. 
The  breadth  of  the  neck  of  one  of  these 
teeth  is  about  one-third  greater  in  front 
than  behind,  and  from  before  backwards 
it  measures  about  four  lines. 

The  upper  cuspidati  are  called  eye- 
teeth  ;  the  lower  are  termed  stomach  teeth . 

These  teeth  are  for  tearing  the  food, 
and  in  some  of  the  carniverous  animals 
where  they  are  very  large,  they  not  only  rend  but  also  hold 
their  prey. 

The  incisors  and  cuspidati  together  are  termed  the  oral 
teeth . 


Fio.  27.  a  a  Front  view  of  the  cuspidati ;   b  I  Palatine  and  lingual  view  ;   c  r 
Side  view. 


62 


ORGANS  OF  MASTICATION. 


THE   BICUSPIDS, 


The  Bicuspids^  (Fig. 
28,)  four  to  each  jaw, 
and  two  on  either  sicle_, 
are  next  in  order  to  the 
cuspidati.  They  are  so 
called  from  their  hav- 
ing two  distinct  promi- 
nences or  cusps,  on  their 
friction  surfaces.  They 
are  also  named  the  small 
molars.  They  are  thick- 
er from  their  buccal  to 
their  palatine  surface 
than  either  of  the  inci- 
sors, and  are  flatter  on  their  sides.  The  grinding  surface 
of  each  is  surmounted  b}^  two  conicle  tubercles,  separated  by 
a  groove  running  in  the  direction  of  the  alveolar  arch  ;  the 
outer  is  larger  and  more  prominent  than  the  inner.  In  the 
lower  jaw  these  tubercles  are  smaller  than  in  the  upper,  and 
on  the  first,  the  inner  is  sometimes  wholly  wanting. 

A  bicusjiis  has  five  surfaces,  namely,  two  appi'oximal,  one 
anterior  and  one  j^osterior,  one  buccal,  one  palatine  or  lingual 
surface,  as  the  tooth  may  be  in  the  upper  or  lower  jaw,  and 
one  grinding  surface.  It  has  also  four  angles,  one  anterior 
and  one  posterior  ixdato-approximal,  and  one  anterior  and 
one  2)osterior  hucco-approximal  angle. 

The  size  of  these  teeth,  like  that  of  the  incisors  and  cus- 
pidati, is  variable.  The  buccal  surface  of  the  crown  of  a 
superior  bicuspis  of  ordinary  size  at  its  broadest  part,  is 
about  three  lines  in  breadth,  while  the  anterior  and  pos- 
terior approximal  surfaces  are  about  four  lines.  Tlie  pala- 
tine is  not  quite  as  wide  as  the  buccal  surface.  All  the 
diameters  of  the  crown  of  a  lower  bicuspis  are  usually  a 


Fio.  28.  a  a,  a  a  Buccal  view  of  the  bicuspids;  6  6, 66  Palatine  and  lingual  view  : 
c  e,  c  c  Side  view. 


ORGANS  OP  MASTICATION. 


63 


little  less  than  those  of  an  upper.     The  entire  length  of  a 
bicuspis  is  ordinarily  about  eleven  lines. 

The  roots  of  the  bicuspids  are,  generally,  simple,  though 
the  groove  is  deeper  than  in  the  cuspidati,  and  not  unfre- 
(|uently  terminates  in  two  roots,  which  have  each  an  open- 
ing for  the  vessels  and  nerves  to  enter.  The  inner  root, 
liowever,  is  always  smaller  than  the  outer. 

THE   MOLARS. 


The  Molars  (Fig.  29)  occupy  the  posterior  part  of  the 

Fia.  29. 


alveolar  arch,  and  are  six  to 
each  jaw,  three  on  either  side. 
They  are  distinguished  by 
their  greater  size,  the  first  and 
second  being  the  largest ;  the 
grinding  surfaces  have  the  en- 
amel thicker,  and  surmounted 
by  four  or  five  tubercles,  or 
cusps,  with  as  many  corres- 
ponding depressions,  arrang- 
ed in  such  a  manner  that  the 
tubercles  of  the  upper  jaw  are 

Fio.  29.  a  a  a,a  a  a  Outer  view  of  the  molars ;  hh  b,hh  b  Inner  view ;  c  c  c,  c  cc 
Side  view. 


64  ORGANS   OF  MASTICATION. 

adapted  to  the  depressions  of  the  lower^  and  vice  versa.  A 
molar,  like  a  biciispis,  has  also  five  surfaces  and  five  angles, 
designated  by  the  names  already  given. 

The  upper  molars  have  three  roots,  sometimes  four,  and 
as  many  as  five  are  occasionally  seen ;  of  these  roots  two  are 
situated  exteriorly,  almost  parallel  with  each  other,  and 
perpendicular ;  the  third  root  forms  an  acute  angle,  and 
looks  to  the  roof  of  the  mouth.  The  former  are  called  the 
buccal  roots,  and  the  latter  the  palatine. 

The  lower  molars  have  but  two  roots,  the  one  anterior, 
the  other  posterior,  are  nearly  vertical  and  parallel  with 
each  other  and  much  flattened  laterally.  The  roots  of  the 
two  first  superior  molars  correspond  with  the  floor  of  the 
maxillary  sinus,  and  sometimes  protrude  into  this  cavity, 
and  their  divergence  secures  them  more  firmly  in  their 
sockets. 

The  last  molar,  called  the  dens  sapientice,  or  wisdom 
tooth,  is  both  shorter  and  smaller  than  the  others,  the  roots 
of  the  upper  wisdom  tooth  are,  occasionally,  united  so  as  to 
form  but  one — while  the  last  molar  of  the  lower  jaw  is  gen- 
erally single  and  of  a  conical  form. 

The  roots  of  the  molar  teeth,  both  of  the  upper  and  lower 
jaw,  after  diverging,  sometimes  approach  each  other,  em- 
bracing the  intervening  bony  partition  in  such  a  manner  as 
to  constitute  an  obstacle  to  their  extraction. 

The  bucco-palatine  diameter  of  the  crown  of  an  upper 
molar  is  usually  a  little  less  than  the  anterio-posterior.  In 
the  lower  jaw,  the  bucco-lingual  and  anterio-posterior  diam- 
eters are  generally  about  the  same. 

The  crown  of  the  first  molar  is  generally  larger  than  the 
second,  and  the  second  larger  than  the  third  or  wisdom 
tooth,  and  the  crown  of  the  last  named  tooth  is  always 
smaller  in  the  upper  than  in  the  lower  jaw.       _^^ 

The  length  of  a  molar  tooth  varies  from  eigbit  to  twelve 
and  a  half  to  thirteen  lines. 

The  molars  and  bicuspids  together  constitute  what  is 
termed  the  buccal  teeth. 


ORGANS  OF  MASTICATION, 


65 


The  use  of  tlie  molars,  as  their  term  signifies,  is  to  tritu- 
rate or  grind  the  food  during  mastication,  and  for  which 
purpose  they  are  admirably  adapted  by  their  mechanical 
arrangement. 

ARTICULATION  OP  THE  TEETH. 

The  manner  in  which  ^'<'-  ^^• 

the  teeth  are  confined  in 
their  sockets,  is  by  a 
union  called  gompliosis, 
from  the  resemblance  of 
this  kind  of  articulation 
to  the  way  in  which  a 
nail  is  received  into  a 
board.  Those  teeth  hav- 
ing but  one  root,  and 
those  with  two  perpen- 
dicular roots  depend 
greatly  on  their  nice 
adaptation  to  their  sockets  for  the  strength  of  their  articu- 
lation. 

Those  having  three  or  four  roots  rely  mostly  on  their  di- 
vergence for  their  firmness. 

But  there  is  another  bond  of  union  by  the  periosteum 
lining  the  alveolar  cavities,  and  investing  the  roots  of  the 
teeth,  also  by  the  blood  vessels  entering  the  apices  of  the 
roots  ;  and,  finally,  by  the  gums,  which  Avill  be  noticed  in 
another  place. 

DIFFERENCE  BETWEEN  THE  TEMPORARY  AND  PERMANENT  TEETH. 

The  temporary  and  permanent  teeth  differ  in  several  re- 
spects, and  on  this  point  I  will  give  Mr.  Bell's  observations: 

"The  temporary  teeth  are,  generally  speaking,  much 
smaller,  than  the  permanent  ;  of  a  less  firm  and  solid  tex- 
ture, and  their  characteristic  forms  and  prominences  much 
less  strongly  marked.     The  incisors  and  cuspidati  of  the 


66  ORGANS  OF  MASTICATION. 

lower  jaw  are  of  the  same  general  form  as  the  adult,  though 
much  smaller^  the  edges  are  more  rounded,  and  they  are  not 
much  more  than  half  the  length  of  the  latter.  The  molars 
of  the  child,  on  the  contrary,  are  considerably  larger  than 
the  bicuspids  which  succeed  them,  and  resemble  very  near- 
ly the  permanent  molars. 

''The  roots  of  these  teeth,  the  molars  of  the  child,  are 
similar  in  number  to  those  of  the  adult  molars,  but  they  are 
flatter  and  thinner  in  proportion,  more  hollowed  on  their  in- 
ner surfaces,  and  diverge  from  the  neck  at  a  more  abrupt 
angle^  forming  a  sort  of  arch." 

RELATIONS  OF  THE  TEETH  OP  THE  UPPER  TO  THOSE  OF  THE  LOWER 
JAW,  WHEN  THE  MOUTH  IS  CLOSED. 

The  crowns  of  the  teeth  of  the  upper  jaw,  generally  de- 
scribe a  rather  larger  arch  than  those  of  the  lower.  The 
upper  incisors  and  cuspidati,  usually  shut  over  and  in  front 
of  the  lower,  but  sometimes  they  fall  plumb  upon  them,  and 
at  other  times,  though  rarely,  they  come  on  the  inside.  The 
external  tubercles  or  cusps  of  the  superior  bicuspids  and 
molars,  generally  strike  on  the  outside  of  those  of  the  corres- 
ponding inferior  teeth.  By  this  beautiful  adaptation  of  the 
tubercles  of  the  teeth  of  one  jaw  to  the  depressions  of  those 
of  the  other,  every  part  of  the  grinding  surfaces  of  the 
organs  are  brought  in  immediate  contact  in  the  act  of  mas- 
tication, which  operation  of  the  teeth,  in  consequence,  is 
rendered  more  perfect  than  it  would  be  if  the  organs  came 
together  in  any  other  manner. 

The  incisors  and  cuspidati  of  the  upper  jaw  are  broader 
than  the  corresponding  teeth  in  the  lower  ;  in  consequence 
of  this  difference  in  the  lateral  diameter  of  the  teeth  of  the 
two  jaws,  the  central  incisors  of  the  upper  cover  the  centrals 
and  about  half  of  the  laterals  in  the  lower,  while  the  supe- 
rior laterals  cover  the  remaining  half  of  the  inferior  and  the 
anterior  half  of  the  adjoining  cuspidati.  Continuing  this 
peculiar  relationship,  the  upper  cuspidati  close  over  the  re- 


ORGANS  OF   MASTICATION.  67 

maining  half  of  the  lower  and  the  anterior  half  of  the  first 
inferior  bicuspids,  while  the  first  superior  bicuspids  cover  the 
remaining  half  of  the  first  inferior  and  the  anterior  half  of 
:he  second.  In  like  manner,  the  second  bicuspids  of  the  up- 
per jaw,  close  over  the  posterior  half  of  the  second  in  the 
lower,  and  the  anterior  third  of  the  first  molars.  The  first 
superior  molars  cover  the  remaining  two-thirds  of  the  first 
inferior  and  the  anterior  third  of  the  second,  while  the  un- 
-"overed  two-thirds  of  this  last  and  anterior  third  of  the  lower 
lentes  sai3ientife^  are  covered  by  the  second  upper  molars. 
The  dentes  sajDientife  of  the  superior  maxillary  being  usual- 
ly about  one-third  less  in  their  anterio-posterior  diameter, 
I'over  the  remaining  two-thirds  of  the  corresponding  teeth 
■n  the  inferior.     (See  Fig.  30.) 

Thus,  from  this  arrangement  of  the  teeth,  it  will  be  seen, 
that  when  the  mouth  is  closed,  that  each  tooth  is  opposed 
to  two,  and,  henoe,  in  biting  hard  substances,  and,  in  mas- 
tication, by  extending  this  mutual  aid_,  a  power  of  resistance 
is  given  to  these  organs  which  they  would  not  otherwise  pos- 
sess. Moreover,  as  a  late  English  writer,  Mr.  Tomes,  very 
justly  observes,  if  one,  or  even  two,  adjoining  teeth  should 
be  lost,  the  corresponding  teeth  in  the  other  jaw  would,  to 
some  extent,  still  act  against  the  contiguous  organs,  and 
thus,  in  some  degree,  counteract  a  process,  first  noticed  by 
that  eminent  dentist,  Dr.  L.  Koecker_,  which  nature  some- 
times sets  up  for  the  expulsion  of  such  teeth  as  have  lost 
their  antagonists. 

The  order  and  time  in  which  both  temporary  and  perma- 
nent teeth  appear,  will  be  noticed  in  the  chapters  on  First 
and  Second  Dentition. 

ACTIVE   ORGANS   OF   MASTICATION. 

The  active  organs  of  mastication  consist  of  the  muscles 
attached,  principally,  to  the  upper  and  lower  maxillary 
bones  ;  by  these,  the  various  motions  concerned  in  mastica- 
tion are  effected. 


68 


ORGANS  OF   MASTICATION. 


They  are  tlie  temporalis,  the  masseter,  pterygoideus  ex- 
terniis,  and  the  pterygoideus  internus. 

The  Temporal  Muscle  (Fig.  31)  is  seen  on  the  side  of  the 
head,  and  has  its  origin  from  the  semicircular  ridge  com- 
mencing at  the  external  angular  process  of  the  os-frontis, 
and  extending  along  this  and  the  parietal  bones — also  from 
the  surfaces  below  this  ridge  formed  by  the  frontal  and 
squamous  portion  of  the  temporal  and  sphenoid  bones  ;  like- 
wise from  the  under  surface  of  the  temporal  aponeurosis,  a 
strong  fascia  covering  this  muscle,  and  is  inserted,  after 
having  its  fibres  to  converge  and  passing  under  the  zygoma, 
in  the  coronoid  process  of  the  lower  jaw,  surrounding  it  on 
every  side  by  a  dense  strong  tendon. 


Fig.  31. 


The  office  of  this  muscle  is  to  bring  tlie  two  jaws  together, 
as  in  the  cutting  and  rending  of  the  food. 

The  Masseter  3fuscie  (Fig.  32)  is  seen  at  the  side  and 
back  i)art  of  the  face  in  front  of  the  meatus  externus,  and 
superficially  under  the  skin.     It  arises  by  two  portions,  the 


Fig.  31.  a  Side  view  of  the  temporal  muscle,  exposed  by  the  removal  of  the 
temporal  fascia;  b  External  lateral  ligament  of  the  lower  jaw;  c  Insertion  of  tem- 
poral muscle  in  coronoid  process  of  lower  jaw. 


ORGANS  OF   MASTICATION.  69 

Fig.  32, 


one  anterior  and  tendinous  from  the  superior  maxilla  where 
it  joins  the  malar  *bone_,  the  other  portions^  mostly  fleshy, 
from  the  inferior  edge  of  the  malar  bone  and  the  zygomatic 
arch  as  far  back  as  the  glenoid  cavity,  and  is  inserted,  ten- 
dinous and  fleshy,  into  the  external  side  of  the  ramus  of  the 
jaw  and  its  angle  as  far  up  as  the  coronoid  process. 

The  use  of  this  muscle,  when  both  portions  act  together_, 
is  to  close  the  jaws  ;  if  the  anterior  acts  alone,  the  jaw  is 
brought  forward,  if  the  posterior,  it  is  drawn  backward. 

Pterygoideus  Externus  (a  and  h  Fig.  33)  arises  from  the 
outer  surface  of  the  external  plate  of  the  pterygoid  process 
of  the  sphenoid  bone,  from  the  tuberosity  of  the  superior 
maxilla ;  also,  from  the  ridge  on  the  sphenoid  bone  separa- 
ting the  zygomatic  from  the  pterygoid  fossa,  and  is  inserted 
into  the  inner  side  of  the  neck  of  the  lower  jaw,  and  capsu- 
lar ligament  of  the  articulation. 

Fig.  32.  Side  view  of  the  muscles  of  external  ear,  cranium  and  face :  o  Occipito- 
frontal is  ;  b  Orbicularis  palpebrarum  ;  c  Pjramidalis  nasi;  d  Compressor  nasi;  e 
and/ Levator  labii  superioris  ahcque  nasi;  </ Zjgomaticus  minor;  A  Zjgomaticus 
major;  i  Masseter  Muscle;  j  Buccinator  muscle;  k  Depressor  anguli  oris;  I  De- 
pressor labii  inferioris ;  m  Orbicularis  oris;  n  Anterior  oris;  o  Superior  oris;  p 
Posterior  oris ;  </  External  lateral  ligament ;  r  Deep-seated  portion  of  masseter 
muscle ;  «  Temporal  fascia. 


to 


ORGANS  OF   MASTICATION. 


Pterygoideus  Iniermis  arises,  tendinous  and  fleshy,  from 
the  inner  surface  of  the  pterygoid  plate — fills  up  the  greater 
part  of  the  pterygoid  fossa,  and  is  inserted,  tendinous  and 
fleshy,  in  the  inner  face  of  the  angle  of  the  inferior  maxilla 
and  rough  surface  above  the  angle. 

These  two  muscles  are  the  great  agents  in  producing  the 
grinding  motion  of  the  jaws,  and  this  they  do  hy  acting 
alternately. 

The  external  one  is  triangular,  having  its  base  at  the 
pterygoid  process  and  running  outwards  and  backwards  to 
the  neck  of  the  condyle.  Wlien  the  pair  act  together,  the 
lower  jaw  is  thrown  forwards.  The  internal  is  strong  and 
thickj  placed  on  the  inside  of  the  ramus  of  the  jaw,  and  run- 
ning downvrards  and  backwards  to  the  angle.  When  it  and 
its  fellow  act  together,  the  jaw  is  drawn  forwards  and  closed. 


FiQ.  33. 


Fia.  33.  a  and  fc  Superior  and  inferior  portions  of  the  pterygoideus  externus; 
c  Pterygoideus. internus;  d  Root  of  zygomatic  process;  e  Condyle. 


CHAPTER     THIRD. 

ORGANS  OF  INSALIVATIOK 

The  organs  of  insalivation  are  the  salivary  glands,  six  in 
number — three  on  each  side  of  the  face,  named  the  Parotid, 
Submaxillary  and  Sublingual. 

These  glands  are  the  prime  organs  in  furnishing  the  sal- 
ivary fluids  to  the  mouth  during  the  process  of  mastication. 

Fig.  34. 


The  Parotid  Gland,  {a  Fig.  34,)  so  called  from  its  situa- 
tion near  the  ear_,  is  the  largest  of  the  salivary  glands.  Its 
form  is  very  irregular  ;  it  fills  all  that  space  between  tlie 
ramus  of  the  inferior  maxilla  and  mastoid  process  of  the 

Fig.  34.  View  of  the  salivary  glands :  a  Parotid  gland;  6  Submaxillary  gland; 
c  Sublingual  glands;  d  Duct  of  Steno  ;  e  Duct  of  Wharton,  or  submaxillary  duct. 


\ 


72  ORGANS   OF  INSALIVATION. 

temporal  bono,  and  as  deep  back  and  even  behind  the  sty- 
loid process  of  the  same  bone.  Its  extent  of  surface  is  from 
the  zygoma  above  to  the  angle  of  the  lower  jaw  below,  and 
from  the  mastoid  process  and  meatus  externus  behind  to  the 
masseter  muscle  in  front,  overlapping  its  posterior  portion. 

This  gland  is  one  of  the  conglomerate  order,  and  consists 
of  numerous  small  granular  bodies  connected  together  by 
cellular  tissue,  and  each  of  which  may  be  considered  a  small 
gland  in  miniature,  as  each  is  supplied  with  an  artery,  vein 
and  secretory  duct. 

The  gland  thus  formed,  presents  on  its  external  surface  a 
pale,  flat,  and  somewhat  convex  appearance. 

It  is  covered  by  a  dense  strong  fascia  extending  from  the 
neck,  attached  to  the  meatus  externus  of  the  ear,  and  sends 
countless  processes  into  every  part  of  the  gland  separating 
its  lobules^  and  conducting  the  vessels  through  its  substance. 

The  use  of  this  gland  is  to  secrete  or  separate  from  the 
blood  the  greater  part  of  the  saliva  furnished  the  mouth. 
As  the  parotid  is,  however,  on  the  outside,  and  at  some  lit- 
tle distance  from  the  mouth,  it  is  furnished  with  a  duct  to 
convey  its  fluid  into  this  cavity  ;  this  ducf  is  called  the  duct 
of  Steno,  or  the  parotid  duct. 

It  is  formed  of  the  excretory  ducts  of  all  the  granules 
composing  this  gland,  which,  successively  uniting  together 
at  last  form  one  common  duct. 

The  duct  of  Steno  commences  at  the  anterior  part  of  the 
gland  and  passes  over  the  masseter  muscle,  on  a  line  drawn 
from  the  lobe  of  the  ear  to  the  middle  part  of  the  upper  lip, 
then  passes  through  a  quantity  of  soft  adipose  matter,  and, 
finally,  enters  the  mouth  by  passing  through  the  buccina- 
tor muscle  and  mucous  membrane  opposite  the  second  mo- 
laris  of  the  upper  jaw. 

The  Submaxillary  {b  Fig.  34)  is  the  next  in  size  of  the  sali- 
vary glands.  It  is  situated  under  and  along  the  inferior 
edge  of  the  body  of  the  lower  jaw,  and  separated  from  the 
parotid  simply  by  a  process  of  fascia  between  the  two. 


I 


ORGANS    OF    INSALIVATION.  73 

It  is  of  oval  form,  pale  color,  and  like  the  parotid,  con- 
sists in  its  structure  of  small  granulations  held  together  by 
cellular  tissue,  and  each  having  a  small  excretory  duct, 
which,  successfully  uniting  with  one  another,  finally  form 
one  common  duct — the  duct  of  Wharton,  which  passes  above 
the  mylo-hyoid  muscle,  and  running  forwards  and  inwards 
c'nters  the  mouth  below  the  tip  of  the  tongue  at  a  papilla 
seen  on  either  side  of  the  freenum  lingute. 

The  use  of  this  gland  is  the  same  as  the  parotid,  to  secrete 
the  saliva,  and  its  duct  is  the  route  by  which  it  is  conducted 
into  the  mouth. 

The  Sublingual  Glands  (c  Fig.  34)  are  the  last  of  the  sali- 
vary order,  and  the  smallest  in  size. 

They  are  situated  beneath  the  anterior  and  lateral  parts 
of  the  tongue,  and  covered  by  the  mucous  membrane,  and 
resting  on  the  mylo-hyoid  muscle. 

They,  like  the  two  glands  just  described,  consist  of  a  gran- 
ular structure  with  excretory  ducts,  which_,  however,  do  not 
unite  into  one  common  duct,  but  enter  the  cavity  of  the 
mouth  by  many  ducts,  whose  openings  are  through  the  mu- 
cous membrane  between  the  tongue  and  inferior  cuspid  and 
bicuspid  teeth. 

Their  office  is  the  same  as  the  parotid  and  submaxillary. 


The  Mucous  Glands,  (Fig.  35.)  Besides  the  glands  fur- 
nishing the  saliva,  there  is  another  series  of  much  smaller 
size,  called  the  mucous  glands.     They  are  simply  the  little 

Fig.  35.  A  rievv  of  inner  side  of  the  lips,  with  the  mucous  membrane  remov- 
ed so  as  to  show  the  labial  and  buccal  glands:  a  a  Ducts  of  Steno;  h  6  Labial 
glands. 

6 


74 


ORGANS   OF   INSALIVATION. 


crypts,  follicles,  or  depressions  every  where  found  in  the 
mucous  membrane  of  the  mouth_,  and  named,  according  tc> 
their  situation,  the  glandular  lahiales,  glandulfe  buccalcS; 
etc.  The  lips,  cheeks  and  palate  are  also  furnished  with 
glands,  which  present  the  true  salivary  structure. 

The  use  of  these  glands  is  to  furnish  the  mucous  of  the 
mouth,  which  they  pour  into  this  cavity,  by  single  orificeSj 
opening  every  where  on  its  surface.  ^ 


I 


CHAPTER    FOURTH. 
ORGANS  OF  DEGLUTITION. 

The  Orgmis  of  Deglutition  succeed  next  in  the  physiologi- 
cal order,  and  are  the  last  in  the  series  belonging  to  the 
mouth  as  concerned  in  the  primary  stages  of  digestion. 

They  consist  of, 

1.  The  Pharnyx, 

2.  The  Soft  Palate,  and 

3.  The  Tongue. 

This  class  of  organs,  as  the  term  implies,  is  concerned  in 
swallowing,  or  conveying  the  food,  after  having  undergone 
the  process  of  mastication ,  and  become  properly  imbued  with 
the  salivary  fluids,  into  the  esophagus,  to  be  thence  conduct- 
ed into  the  stomach  for  the  after  stages  of  digestion. 

The  Pharynx  (Fig.  36)  is  a  large  musculo-membranous 
bag,  opening  in  front,  and  situated  behind  the  mouth,  the 
nares,  and  soft  palate.  It  is  connected  above  by  a  strong 
aponeurosis  to  the  cribriform  process  of  the  occipital  bone, 
and  extends  below  as  far  as  the  fourth  and  fifth  cervical  ver- 
tebra ;  behind^  it  is  attached  to  the  bodies  of  the  vertebrae, 
and  laterally,  it  is  connected  to  the  expanded  cornua  of  the 
hyoid  bone. 

By  these  several  attachments,  it  forms  a  constant  and  un- 
occupied cavity,  in  which  may  be  seen  seven  openings  lead- 
ing from  it,  in  various  directions.  The  two  posterior  nares 
are  at  the  upper  and  nasal  portion  ;  on  each  side  of  these, 
and  at  the  back  part  of  the  inferior  spongy  bones,  are  the 
two  eustachian  tubes  leading  to  the  ear.  In  front  and  below 
the  velum  is  the  opening  into  the  mouth,  and  still  lower 
down  the  openings  for  the  glotti  and  the  commencement  of 
the  esophagus. 


76 


ORGANS  OF   DEGLUTITION. 

FiQ.  36. 


The  Muscles  of  the  Pharynx  are  four  in  number^  namely  : 

1.  The  Superior — constrictor  pharyngis  superior. 

2.  The  Middle — constrictor  pharyngis  medius. 

3.  Inferior  constrictor  of  the  pharynx. 

4.  Stylo  pharyngeus.  ' 

The  constrictors  are  seen  on  tlie  posterior  part  of  the 
pharynx  after  removing  the  cervical  vertebras,  and  present 
very  much  the  appearance  of  one  continued  sheet  of  muscle. 

The  Superior  Constrictor  (a  a  Fig.  36)  arises  from  the 
cuneiform  process  of  the  occipital  bone,  from  the  lower  part 
of  the  internal  pterygoid  plate  of  the  sphenoid  bone,  from 

Fio.  36.  Front  view  of  the  muscles  of  the  palate,  and  posterior  portion  of 
pharynx :  a  a  Superior  constrictor  of  the  pharynx;  b  b  Middle  constrictor  of  the 
pharynx;  c  c  Inferior  constrictor  of  the  pharynx:  d  d  Levator  palati ;  e  Uvula; 
//Anterior  half  arch,  containing  the  constrictor  isthmi  faucium  muscles:  g  Ten- 
sor, or  circumflexus  palati. 


ORGANS   OF   DEGLUTITION.  tT 

the  pterygo-maxillary  ligament,  and  from  the  posterior  third 
of  the  mylo-hyoid  ridge  of  the  lower  jaw,  near  the  root  of 
the  last  molar  tooth.  It  is  inserted  with  its  fellow  into  the 
middle  tendinous  line  on  the  back  of  the  pharynx. 

The  Middle  Constrictor'  of  the  pharynx  (b  h  Fig.  36)  arises 
from  the  appendix  and  cornii  of  the  os-hyoides,  and  from 
the  thyro-hyoid  ligament ;  its  fibres  ascend,  run  trans- 
versely and  descend,  giving  a  triangular  appearance  ;  the 
upper  ones  overlap  the  superior  constrictor,  "while  the  lower 
are  beneath  the  inferior,  and  the  whole  pass  back  to  be  in- 
serted into  the  middle  tendinous  line  of  the  pharynx. 

The  Inferior  Constrictor  of  the  pharynx  (c  c  Fig.  36) 
arises  from  the  side  of  the  thyroid  cartilage  and  its  inferior 
cornu,  and  from  the  side  of  the  cricoid  cartilage,  and  is  in- 
serted with  its  fellow  in  the  middle  line  on  the  back  of  the 
pharynx. 

This  is  the  largest  of  the  constrictor  muscles,  and  overlaps 
the  constrictor  medius. 

The  action  of  all  these  muscles  is,  to  lessen  the  cavity  of 
the  pharynx,  and  thus  compel  the  food  to  take  the  down- 
ward direction  into  the  esophagus.  The  pharynx  is  lined 
by  mucous  membrane. 

The  Stylo  Pharyngeus  arises  from  the  root  of  the  styloid 
process,  and  is  inserted  into  the  side  of  the  pharynx  and 
corner  of  the  os-hyoides  and  thyroid  cartilage.  It  is  a  large 
and  narrow  muscle,  and  gets  to  the  pharynx  between  the 
upper  and  middle  constrictors.  Its  use  is  to  elevate  and 
draw  forward  the  pharynx,  to  receive  the  food  from  the 
mouth,  also  to  raise  the  larynx. 

THE  SOFT  PALATE. 

The  Soft  Palate  (e  Fig.  36)  is  a  movable  curtain,  com- 
posed of  mucous  membrane,  enclosing  several  muscles.  It 
is  situated  at  tlie  back  part  of  the  mouth  between  this  cav- 


\ 


78 


ORGANS  or  DEGLUTITION. 


ity  and  the  pharynx,  is  connected  above  to  the  posterior 
edge  of  the  hard  palate_,  and  laterally  to  the  side  of  the 
tongue  and  pharynx. 

By  this  arrangement,  the  soft  jjalate  is  made  a  portion  of 
a  lunated  or  arched  form  between  the  cavity  of  the  mouth 
and  the  pharynx. 

In  the  centre  of  this  arch  an  oblong  body  is  suspended, 
called  the  uvula,  which  divides  the  soft  palate  into  lateral 
half  arches,  that  pass  from  the  uvula  on  either  side  to  the 
root  of  the  tongue. 

There  is  also  seen  passing  from  the  uvula  on  each  side  to 
the  pharynx,  two  other  arches,  which,  from  being  behind 
the  first,  are  called  the  posterior  lateral  half  arches. 

Between  the  anterior  and  posterior  lateral  half  arches  on 
either  side  there  is  a  cavity  containing  the  tonsil  glands. 

This  cavity  is  the  fauces,  and  the  opening  between  the 
anterior  lateral  half  arches  is  the  isthmus  of  the  fauces. 

The  muscles  of  the  palate  are  four  pair,  and  one  single 
one,  namely : 

1.  The  Levator  Palati. 

2.  The  Tensor  or  Circumflexus  Palati. 

3.  Constrictor  Isthmi-Faucium,  or  Palato  Glossus. 

4.  Palato-Pharyngeus. 

5.  Azygos-Uvulee  is  the  single  muscle. 

Fio.  37. 

The  Levator  Palati  (b  b 
Fig.  37)  arises  from  the  point 
of  the  petrous  bone  and  ad- 
'c  joining  portion  of  the  eusta- 
chian tube,  descends  and  is 
inserted  into  the  soft  palate. 
Its  use  is  to  raise  the  palate. 


Fig.  37.  Posterior  view  of  the  muscle  of  the  soft  palate  :  a  Roof  of  the  mouth  or 
hard  palate  ;  b  b  Levator  palati ;  c  Basilar  portion  of  sphenoid  bone ;  d  d  Eusta- 
chian tubes  ;  e  Tensor  or  circumflexus  palati ;  /  Azygos-uvulffi ;  g  g  Palato-pharyn- 
geu8,  in  posterior  half  arch. 


ORGANS  OF  DEGLUTITION.  TO 

The  Tensor  Circumflexus,  or  Palati,  arises  from  the  base 
of  the  pterygoid  process  of  the  sphenoid  bone,  from  the 
eustachain  tube,  descends  in  contact  with  the  internal  ptery- 
goid muscle,  to  the  hamulus,  round  which  it  winds,  and  is 
inserted  into  the  soft  palate  where  it  expands  and  joins  its 
fellow.     Its  office  is  to  spread  the  palate. 

Constrictor  Isthmi-Faucium  occupies  the  anterior  lateral 
lialf  arches  of  the  palate  ;  it  arises  from  the  side  of  the 
tongue  near  its  root,  and  is  inserted  in  the  velum  near  the 
uvula. 

It  draws  the  velum  down  and  closes  the  opening  into  the 
fauces. 

Palato-Pharyngeus  occupies  the  posterior  lateral  half 
arches  of  the  palate,  and  extends  from  the  soft  palate  be- 
hind, near  the  uvula  as  its  origin,  and  is  inserted  into  the 
pharynx,  between  the  middle  and  lower  constrictors  and 
into  the  thyroid  cartilage. 

Its  use  is  to  draw  down  the  velum  and  raise  the  pharynx. 

Azygos-Uvulce  arises  from  the  posterior  spine  of  the  palate 
bones  at  the  termination  of  the  palate  suture,  runs  along  the 
central  line  of  the  soft  palate,  and  ends  in  the  point  of  the 
uvula.     It  raises  and  shortens  the  uvula. 

It  is  thus  seen  that  the  various  muscles  of  the  soft  palate 
are  all  concerned,  more  or  less,  in  conducting  the  food  into 
the  pharyngeal  cavity.  The  elevators  raise  the  palate^  and 
at  the  same  time  protect  the  posterior  nares  from  regurgita- 
tion of  the  food,  while  the  tensor  puts  it  on  the  stretch,  and 
after  having  passed  the  velum,  the  constrictor  isthmi-fau- 
cium  and  palato-pharyngeus  draw  the  palate  down,  and 
thus  close  the  opening  into  the  mouth,  after  which  the  food, 
as  already  mentioned,  is  graspsd  by  the  constrictor  muscles 
of  the  pharynx,  and  conveyed  into  the  esophagus. 


80 


ORGANS   OF  DEGLUTITION. 


The  Tonsils  are  two  bodies,  each  about  the  size  of  an 
almond,  seen  at  the  root  of  the  tongue  on  its  side,  occupying 
the  cavity  between  the  anterior  and  posterior  half  arches. 
They  consist  of  a  congeries  of  mucous  glands,  forming  some- 
what of  an  oval  body,  whose  enlargement  is  a  frequent  ob- 
stacle to  deglutition,  and  by  their  locality  near  the  mouths 
of  the  eustachian  tubes,  a  frequent  cause  of  obstruction  and 
deafness. 

THE    TONGUE. 


Fig.  38.  The  Touguc  is  a  very  compli- 

cated organ,  for  it  consists  of  a 
great  variety  of  parts,  and  per- 
forms a  great  variety  of  functions, 
and  although  we  have  arranged 
it  here  as  one  of  the  organs  of 
deglutition,  it  is,  nevertheless,  a 
glandular  organ,  to  secrete ;  a 
sentient  organ,  to  feel  and  taste  ; 
and,  likewise,  an  intellectual  or- 
gan, to  assist  in  producing  speech . 
The  tongue  is  divided  into  its 
apex^  bodji  and  root ;  the  apex  is 
the  anterior  loose  and  sharp  por- 
tion— the  root  which  is  thin,  is 
attached  to  the  os-hyoides  and  is 
posterior — while  the  body,  which  occupies  the  centre,  is 
thick  and  broad  ;  it  is  confined  in  its  situation  by  reflections 
of  the  mucous  membrane,  to  be  noticed  hereafter. 

The  upper  surface  is  rough  from  numerous  eminences 
called  the  papillas — which  are  distinguished  into  :  1 .  The 


Fro.  38.  A  front  view  of  the  upper  surface  of  the  tongue  and  palatine  arch  ;  a  a 
Posterior  lateral  half  arches,  containing  the  palato-pharyngoi  muscles  and  the  ton- 
sils ;  b  Epiglottis  cartilage ;  c  c  Ligament  and  mucous  membrane,  extending  from 
root  of  tongue  to  base  of  epiglottis  cartilage ;  d  Foramen  cecum  or  central  one  of 
lenticular ;  e  Lenticular  papillse ;  /  Filliform  papillae ;  g  Conical  papillje,  scattered 
urer  whole  surface  of  the  tongue  ;  h  Point  of  tongue,  »  i  Fungiform  papillae  seen 
on  borders  of  the  tongue. 


I 


ORGANS   OF  DEGLUTITION.  81 

Lenticular;  2.  The  Fungiform;  3.  The  Conicle  ;   and,  4. 
Filliform  papilla. 

The  Lenticular  are  the  largest  in  size,  situated  at  the  root 
of  the  tongue,  are  nine  or  more  in  number,  and  arranged 
after  the  manner  of  the  letter  A,  with  the  concavity  looking 
forwards. 

They  are,  generally,  spherical  in  shape,  and  consist  sim- 
ply of  mucous  follicles  like  those  of  the  lips,  palate,  etc. 
Behind  these  is  observed  a  depression  called  the  foramen 
cecum. 

The  Fungiform  are  next  in  size,  and  more  numerous; 
they  are  found  near  the  borders  of  the  tongue,  and  present 
a  round  head  supported  on  a  thin  pedicle. 

The  Conicle  are  still  more  numerous,  and  are  seen  scat- 
tered over  the  whole  surface  of  the  tongue,  reaching  from 
the  lenticular  to  the  apex.  They  are  minute  and  tapering, 
and  resemble  small  cones. 

The  Filliform  papilla}  are  the  smallest  of  all,  and  occupy 
the  intervals  between  the  others,  and  are  also  found  at  the 
apex  of  the  tongue. 

All  these  papillte,  except  the  lenticular,  from  their  being 
so  freely  supplied  with  mucous  and  blood  vessels,  and  hav- 
ing a  peculiar  arrangement,  belong  essentially  to  the  func- 
tion of  taste. 

The  great  body  of  the  tongue,  however,  is  muscular  in  its 
structure,  and  its  muscles  are  as  follows. 

1.  The  Stylo-Glossus. 

2.  Hyo-Glossus. 

3.  Genio-Hyo-Glossus. 

4.  Lingualis. 

These  constitute  the  muscles  proper  of  the  tongue.     But 


82 


ORGANS   OF  DEGLUTITION. 


there  are  some  others  which  act  more  or  less  indirectlly  ou 
the  tongue  and  lower  jaw.     They  are 

1.  The  Digastricus. 

2.  The  Mylo-Hyoideus,  and 

3.  The  Genio-Hyoideus. 

The  Stylo-Glossus  arises  from  the  point  of  the  styloid  pro- 
cess and  stylo-maxillary  ligament.  It  is  inserted  into  the 
side  of  the  tongue  near  its  root,  its  fibres  running  to  the  tip. 

The  Hyo-Glossus — a  thin,  broad,  quadrilateral  muscle, 
has  its  origin  from  the  body,  cornu,  and  appendix,  of  the 
os-hyoides^  and  is  inserted  into  the  side  of  the  tongue,  form- 
ing the  greater  part  of  its  bulk. 

Fig.  39. 


The  Genio- Hyo-Glossus  is  a  triangular  muscle,  situated  on 

Fig.  39.  Lateral  view  of  tongue  and  its  principal  muscles :  a  Mastoid  process ; 
6  Coronoid  process;  c  Stylo-glossus  muscle;  <i  Hyo-glossus  muscle;  e  Genio-hyo- 
gloesus  muscle ;  /  Genio-hyoid  muscle ;  g  Section  of  lower  jaw  at  symphysis ;  h 
Styloid  process. 


ORGANS  OF   DEGLUTITION.  83 

tlie  inside  of  the  last,  and  having  its  origin  from  the  upper 
tubercle  on  the  posterior  symphysis  of  the  lower  jaw,  and 
its  insertion  into  the  body  of  the  os-hyoides  and  the  whole 
length  of  the  tongue  from  its  base  to  its  apex.  The  fibres 
of  this  muscle  radiate  in  various  directions  through  the 
tongue. 

The  Lingualis  has  its  origin  on  the  under  surface  of  the 
tongue,  extending  from  its  base  to  the  apex,  and  so  inter- 
mingling with  the  other  muscles  as  to  be  considered  rather 
a  part  of  them  than  a  distinct  one. 

The  Digastricus,  as  its  name  implies,  consists  of  two 
bellies  united  in  the  middle  by  a  tendon  which  passes 
through  the  stylo-hyoid  muscle,  and  is  attached  to  the 
hyoid  bone.  Of  the  two  bellies,  the  one  is  posterior,  and 
occupies  the  fossa  at  the  end  of  the  mastoid  process  of  the 
temporal  bone — the  other  is  anterior,  and  extending  from 
the  os-hyoides  to  the  base  of  the  lower  jaw  by  the  side  of  the 
symphysis. 

The  Mylo-Hyoideus  forms  the  floor  of  the  mouth  and  is  a 
broad  plane  of  muscular  fibres,  having  its  origin  from  the 
myloid  ridge  on  the  posterior  surface  of  the  inferior  maxilla, 
and  its  insertion  into  the  body  of  the  os-hyoides. 

The  Genio-Hyoideus  is  a  short,  round  muscle  beneath  the 
last,  and  has  its  origin  from  the  lower  tubercle  on  the 
back  of  the  symphysis  of  the  -lower  jaw,  and  insertion  into 
the  body  of  the  os-hybides. 

All  uuese  muscles^  by  their  separate  or  combined  action, 
have  the  power  of  throwing  the  tongue  into  every  possible 
variety  of  position  and  motion  as  concerned  in  the  functions 
of  deglutition,  suction  and  speech.  They  can  elevate,  de- 
press or  turn  the  tongue  to  either  side  ;  they  can  protrude 
it  from  the  mouth  or  draw  it  back  to  the  pharynx — make 


84  ORGANS   OF   DEGLUTITION. 

its  njjper  surface  or  dorsum  either  convex  or  concave,  and, 
finally,  can  turn  the  tip,  as  is  well  known,  either  upwards, 
downwards,  backwards  or  laterally. 

THE   MUCOUS   MEMBRANE   LINING   THE   MOUTH. 

The  whole  interior  cavity  of  the  mouth,  palate,  pharynx 
and  lips,  are  covered  by  mucous  membrane,  forming  folds 
or  duplicatures  at  different  points,  called  fraeni  or  bridles. 
Beginning  at  the  margin  of  the  lower  lip,  this  membrane 
can  be  traced  lining  its  posterior  surface,  and  from  thence  is 
reflected  on  the  anterior  face  of  the  lower  jaw,  where  it 
forms  a  fold  opposite  the  symphysis  of  the  chin,  the  frrenum 
of  the  lower  lip  ;  it  is  now  traced  to  the  alveolar  ridge, 
covering  it  in  front,  and  i3assing  over  its  posterior  surface, 
where  it  enters  the  mouth.  Here  it  is  reflected  from  the 
posterior  symphysis  of  the  lower  jaw  to  the  under  surface  of 
the  tongue,  where  it  forms  a  fold  or  bridle  called  the 
frcenurii  linguce.  It  now  spreads  over  the  tongue,  covering 
its  dorsum  and  sides  to  the  root,  from  whence  it  is  reflected 
to  the  epiglottis,  forming  another  fold  ;  from  this  point  it 
can  be  followed^  entering  the  glottis  and  lining  the  larynx, 
trachea,  etc. 

In  the  same  way,  commencing  at  the  upper  lip,  it  is  re- 
flected to  the  upper  jaw,  and  at  the  upper  central  incisors 
forming  a  fold,  i\\Qfhenuin  of  the  upper  lip  ;  from  this  it 
passes  over  the  alveolar  ridge  to  the  roof  of  the  mouth, 
which  it  completely  covers,  and  extends  as  far  back  as  the 
posterior  edge  of  the  palate  bones  ;  from  this  it  is  reflected 
downwards  over  the  soft  palate,  or,  more  strictly  speaking, 
the  soft  palate  is  formed  by  the  duplicature  of  this  mem- 
brane at  this  point,  between  the  folds  of  which  are  placed 
the  muscles  of  the  palate  already  described. 

From  the  palate  it  is  traced  upwards  and  continuous  with 
the  membrane  lining  the  nares^  and  downwards  with  the 
same  lining  the  pharynx,  esophagus,  stomach  and  in- 
testinal canal. 


ORGANS   OF   DEGLUTITION.  85 

The  mucous  membrane,  after  entering  the  nostrils  and 
lining  the  roof,  floor,  septum  nasi,  and  turbinated  bones, 
enters  the  maxillary  sinus  between  the  middle  and  lower 
spongy  bones,  and  lines  the  whole  of  this  great  and  impor- 
tant cavity  of  the  superior  maxilla. 

Many  mucous  glands  or  follicles,  already  enumerated,  are 
scattered  over  the  whole  of  this  membrane,  and  furnish  the 
mouth  with  its  mucus. 

As  this  membrane  passes  over  the  superior  surface  of  the 
alveolar  ridge  of  both  jaws,  its  texture  becomes  changed, 
and  receives  the  name  of  gums. 

THE   GUMS. 

The  gums  are  composed  of  thick,  dense,  mucous  mem- 
brane, adhering  to  the  periosteum  of  the  alveolar  processes, 
and  closely  surrounding  the  necks  of  the  teeth,  vdiere  they 
are  reflected  upon  themselves,  forming  a  free  border  or  mar- 
gin, presenting  a  scalloped  or  festooned  appearance.  The 
longest  portions  are  situated  in  the  interdental  spaces  be- 
tween the  teeth.  The  reflected  portion  unites  with  the  peri- 
osteum of  the  roots  at  the  necks  of  the  teeth,  and  becomes 
continuous  with  it.  The  texture  of  the  gums  differs  mate- 
rially from  that  of  the  membrane  of  which  they  are  com- 
posed. Externally,  it  is  very  similar  to  this  membrane,  but 
internally,  it  is  fibro-cartilaginous.  The  gums,  when  in  a 
healthy  state,  vary  in  thickness  from  one-third  to  three- 
fourths  of  a  line. 

The  gums  are  remarkable  for  their  insensibility  and  hard- 
ness in  the  healthy  state,  but  exhibit  great  tenderness,  upon 
the  slightest  injury  when  diseased. 

In  the  infant  state  of  the  gums,  the  central  line  of  both 
dental  arclies  present  a  white,  firm,  cartilaginous  ridge, 
which  gradually  becomes  thinner  as  the  teeth  advance,  and 
in  old  age,  after  the  teeth  drop  out^  the  gums  again  resume 
somewhat  their  former  infantile  condition,  showincr,  "sec- 
ond-childhood." 


86  ORGANS  OF  DEGLUTITION. 

The  gums  being  endowed  with  a  high  degree  of  vascular- 
ity, indicate  very  correctly,,  as  the  author  has  stated  in 
another  part  of  the  work,  the  state  of  the  constitutional 
health. 

THE  ALVEOLO-DENTAL  PERIOSTEUM. 

This  membrane  may  be  properly  noticed  here,  as  it  is 
considered  by  some  as  continuous  with  the  gums.  It  lines 
the  alveolar  cavities  or  sockets  of  the  teeth^  covers  the  roots 
of  each — is  attached  to  the  gums  at  the  necks,  and  to  the 
blood-vessels  and  nerves  where  they  enter  the  roots  of  the 
teeth  at  their  apices  ;  and,  further^  Mr.  Thomas  Bell  be- 
lieves it  is  traced  into  the  cavities  of  the  teeth,  forming  their 
lining  membrane,  and  continuous  with,  or  the  same  as  that 
of,  the  pulp. 

The  original  sac  for  the  pulp  has  been  stated  in  another 
place  to  consist  of  two  membranes,  an  outer  and  an  inner  ; 
these  are  attached  to  the  gums,  and  when  the  teeth  come 
through  these  membranes  and  the  gums,  the  remaining 
part  of  the  sac,  especially  its  outer  coat,  is  supposed  by  some 
to  constitute  the  alveolo-dental  periosteum,  and  to  be  con- 
tinuous with  the  gums — while,  on  the  other  hand,  Mr.  Bell 
believes  both  membranes  of  the  sac  wholly  absorbed,  and 
that  the  true  alveolo-dental  periosteum  is  the  same  as  the 
periosteum  covering  the  upper  and  lower  maxillary  bones, 
and  continues  into  the  alveolar  cavities,  lining  their  parie- 
tes,  and  thence  reflected  on  the  roots  of  the  teeth. 

It  matters  little  whether  this  membrane  be  a  continuation 
of  the  gums,  the  remains  of  the  pulp  sac,  or  the  extension 
of  the  periosteum  of  the  maxillary  bones  into  the  alveolar 
cavities,  since  the  great  practical  truth  still  remains  the 
same,  that  there  is  a  membrane  lining  the  alveolar  cavities 
and  investing  the  roots  of  the  teeth,  and  that  this  membrane 
is  fibrous,  and  constitutes  the  bond  of  union  between  the 
alveolar  cavities  and  the  roots  of  the  teeth . 


I 


ORGANS  or   DEGLUTITION.  87 

The  Dental  Ligament,  so  recently  discovered  by  a  dentist, 
formerly  of  Virginia,  but  now  of  Philadelphia,  as  attached 
to  the  necks  of  the  teeth,  and  confirmed,  I  am  sorry  to  add, 
by  Dr.  Goddard,  bears  no  more  resemblance  to  true  ligament 
than  the  nails  do  to  bone.  It  consists  of  the  fibres  that 
unite  the  alveolar  to  the  dental  periosteum,  and  which, 
according  to  the  last  named  gentleman,  "are  very  numerous 
just  at  the  margin  of  the  alveolus." 


CHAPTER    FIFTH. 

BLOOD-VESSELS  OF   THE  MOUTH. 

The  arteries  that  supply  tlie  mouth  come  from  the  exter- 
nal carotid.     This  is  a  division  of  the  common  carotid  which 

Fia.  40, 


Fio.  40.  A  view  of  the  arteries  supplying  one  side  of  the  mouth  and  face  :  a  a 
Kxternal  carotid  artery  ;  h  Inferior  maxillary  bone  with  the  anterior  plate  removed 
so  aa  to  expose  the  roots  of  the  teeth  and  the  inferior  dental  artery ;  c  Posterior 
mental  foramen,  through  which  the  inferior  dental  artery  passes  ;  d  Anterior  men- 
tal foramen,  where  the  same  artery  comes  out  to  supply  the  muscles  of  the  lower 
lip ;  e  e  Superior  maxillary  bone  with  the  lower  part  of  the  anterior  and  outer 
wall  removed,  showing  the  arteries  going  to  the  roots  of  the  teeth  and  cavity  ot 
the  antrum  ;  /  Infia-orbitar  foramen,  through  which  passes  the  infra-orbitar  ar- 
tery ;  h  Xasal  process  of  superior  maxillary  bone;  t  Pterygoideus  internus  muscle; 
./  Angle  of  inferior  maxillary  bone  ;  A;  Orbit  of  the  eye  ;  I  Superior  thyroid  artery  ; 
m  VI  Facial  artery  ;  u  Terminating  branch  of  the  lingual  artery;  o  Termination  of 


BLOOD-VESSELS   OF   THE  MOUTH.  89 

arises  on  the  right  from  the  arteria-innominata,  and  on  the 
left  from  the  arch  of  the  aorta — after  passing  up  the  neck  on 
either  side  along  the  course  of  the  sterno-cleido  mastoid 
muscles,  it  divides  on  a  level  with  the  top  of  the  thyroid 
cartilage  into  its  two  great  branches — the  external  and  in- 
ternal carotid  arteries. 

The  Internal  Carotid  Artery  has  a  tortuous  course,  is  first 
to  the  outside  and  behind  the  external  carotid — then  ascends 
in  front  of  the  vertebral  column  by  the  side  of  the  pharynx 
and  behind  the  digastric  and  styloid  muscles  to  the  foramen 
caroticum  in  the  petrous  portion  of  the  temporal  bone — 
thence  it  traverses  the  canal  in  this  bone  and  enters  the 
brain,  supplying  it  with  the  most  of  its  vessels,  not  giving 
any  to  the  mouth. 

The  External  Carotid  {a  a  Fig.  36)  extends  from  the  top 
of  the  larynx  to  the  neck  of  the  condyle*  of  the  lower  jaw  ; 
it  is  at  first  anterior  and  to  the  inside  of  the  internal  carotid, 
soon  gets  to  the  outside,  then  passes  under  the  digastric  and 
stylo-hyoid  muscles  and  lingual  nerve,  becomes  imbedded 
in  the  parotid  gland,  and  finally  terminates  at  the  point  in- 
dicated in  the  temporal  and  internal  maxillary  arteries. 

The  branches  of  this  artery  supply  all  the  organs  belong- 
ing to  the  four  primary  stages  of  digestion,  namely^  those 
of  Prehension,  Mastication,  Insalivation  and  Deglutition. 

ARTERIES  OF  PREilEXSCiN. 

These  belong,  principally,  to  the  lips,  and  come  chiefly 
from  the  facial  artery. 

The  Facial  Artery  is  the  third  branch  of  the  external 
carotid.      It  ascends  to  the   submaxillary    gland,    behind 

external  carotid  into  the  temporal  and  internal  maxillary  branches ;  p  Temporal 
artery;  5  Internal  Maxillary  artery  ;  r  r  Inferior  dental  artery:  «  Deep  temporal 
branch;  «  Transverse  arterj- of  the  face;  !<  k  Muscular  branches  ;  t- Alveolar  branch ; 
to  Posterior  dental  branch  ;  x  Terminal  branch  of  infra-orbitar  artery ;  ij  Nasal 
branch  of  the  facial ;  z  Submental  branch. 


90  BLOOD-VESSELS   OF  THE  MOUTH. 

wliicli  it  passes  on  the  bone  of  the  lower  jaw — thence  it  goes 
in  front  of  the  masseter  muscle  to  the  angles  of  the  mouth, 
and,  finally,  terminates  at  the  side  of  the  nose  by  anasto- 
mosing with  the  ophthalmic  arteries. 

In  its  course  it  gives  off  the  submental^  inferior  labial, 
superior  and  inferior  coronary  arteries,  which  mainly  supply 
the  elevators,  depressors,  and  circular  muscles  of  the  mouth, 
those  agents  concerned  in  the  first  steps  of  digestion — the 
prehension  of  the  food. 

ARTERIES  OF  MASTICATION. 

These  come  from  the  internal  maxillary  and  the  tem-po- 
ral — the  two  terminating  branches  of  the  external  carotid. 

The  Internal  Maxillary  Artery  commences  in  the  sub- 
stance of  the  parotid  gland — then  goes  horizontally  behind 
the  neck  of  the  condyle  of  the  lower  jaw  to  the  pterygoid 
muscles,  between  which  it  passes,  and  then  proceeds  for- 
wards to  the  tuberosity  of  the  superior  maxillary  bone  ; 
from  thence  it  takes  a  vertical  direction  upwards  between 
the  temporal  and  external  pterygoid  muscles  to  the  zygo- 
matic fossa,  where  it  again  becomes  horizontal,  and,  finally_, 
ends  in  the  spheno-maxillary  fossa  by  dividing  into  several 
branches. 

Those  branches  of  the  internal  maxillary  supplying  the 
passive  organs  of  mastication,  or  the  superior  and  inferior 
maxillary  bones,  with  the  teeth,  are, 

1.  Inferior  Maxillary  or  Dental  Artery, 

2.  The  Alveolar  or  Superior  Dental, 

3.  The  Infra-Orbital, 

4.  The  Superior  Palatine,  and 

5.  The  Spheno-Palatine. 

The  Inferior  Dental  Artery  enters  the  posterior  mental 
foramen  of  the  lower  jaw,  jiasses  along  the  dental  canal  be- 
neath the  roots  of  the  teeth — sending  up  a  twig  through 


BLOOD-VESSELS   OF  THE  MOUTH.  91 

the  aperture  of  each  to  tlie  pulps  of  tlie  teeth  as  it  passes 
along^  and,  finally,  escapes  at  the  anterior  mental  foramen 
on  the  face — a  branch  of  it,  however,  continues  forwards  to 
supply  the  incisors. 

The  Superior  Dental  Artery  winds  around  the  maxillary 
tuberosity  from  behind  forwards,  sending  off  twigs  through 
the  posterior  dental  canals  which  supply  the  molars,  and 
go  to  the  maxillary  sinus — while  the  main  branch  is  contin- 
ued forward,  furnishing  the  gums. 

The  Infra-Orhitar  Artery  enters  the  infra-orbitar  canal, 
traverses  its  whole  extent,  and  comes  out  at  the  foramen  of 
the  same  name,  upon  the  face ;  just  before  it  emerges  it 
sends  down  the  anterior  dental  canal  a  twig  for  the  incisors 
and  cuspidati. 

The  Superior  Palatine  descends  behind  the  superior  max- 
illary bone,  passes  through  the  posterior  palatine  canal  to 
the  roof  of  the  mouth,  and  supplies  the  palate,  gums  and 
velum  pendulum  palati.  It  also  sends  off  a  small  branch 
through  the  foramen  incisivum  to  the  nose. 

The  Sphe7io-Palatine  entering  the  back  part  of  the  nose 
through  the  spheno-palatine  foramen,  is  distributed  upon  the 
pituitary  membrane. 

The  arteries  supplying  the  active  organs  of  mastication — 
the  temporal,  masseter,  and  pterygoid  muscles,  are, 

The  temporal,  anterior  and  posterior  deep — the  pterygoid 
and  masseteric  branches  of  the  internal  maxillary  artery — 
while  the  temporal  artery,  which  is  the  other  terminating 
branch  of  the  external  carotid,  gives  off  the  middle  tempor- 
al artery,  to  the  temporal  muscle,  and  a  branch,  the  trans- 
verse artery  to  the  masseter. 

The  Temporal  Artery  begins  in  the  substance  of  the  paro- 
tid gland  at  the  neck  of  the  condyle  of  the  lower  jaw,  mounts 
over  the  zygoma  in  front  of  the  meatus,  and  ascends  about 


92  BLOOD-VESSELS  OF   THE  MOUTH. 

an  inch  or  more  when  it  divides  into  its  anterior  and  poste- 
rior branches. 

ARTERIES   OF   LNSALIVATION. 

These  belong  to  the  salivary  glands.  The  parotid  is  sup- 
plied by  the  posterior  auricular,  a  branch  of  the  external 
carotid,  and  by  the  transverse  artery  of  the  temporal.  The 
submaxillary  is  supplied  by  the  facial  and  the  sublingual  by 
a  branch  of  the  lingual  artery. 

ARTERIES   OP   DEGLUTITION. 

The  pharynx,  soft  palate  and  tongue,  are  the  organs  sup- 
plied by  these  arteries. 

The  Arteries  of  the  Pharynx  are  the  superior  and  inferior 
pharyngeal  and  inferior  palatine. 

The  superior  is  a  branch  of  the  internal  maxillary,  and  is 
spent  upon  the  upper  part  of  the  pharynx,  and  sends  a 
branch  through  the  pterygo-palatine  foramen  to  supply  the 
arch  of  the  palate  and  contiguous  parts.  The  inferior  is  a 
branch  of  the  external  carotid,  and  in  its  course  upwards 
towards  the  basis  of  the  cranium,  it  sends  several  branches 
to  the  pharynx  and  contiguous  deep-seated  parts.  The  in- 
ferior jialatine  is  given  off  by  the  facial. 

The  Arteries  of  the  Soft  Palate  are. 

The  superior  palatine,  inferior  palatine,  and  inferior  pha- 
ryngeal branches. 

The  Superior  Palatine  comes  off  from  the  internal  maxil- 
lary behind  the  orbit  in  the  pterygo-maxillary  fossa,  de- 
scends in  the  posterior  palatine  canal,  comes  out  on  the  back 
part  of  the  roof  of  the  palate  through  a  foramen  of  the  same 
name,  and  proceeds  inwards  and  forwards,  supjdying  the 
soft  palate  and  mucous  membrane. 


BLOOD-VESSELS  OF   THE  MOUTH.  93 

The  Inferior  Palatine  is  a  brancli  of  the  facial,  and  pass- 
es up  between  the  stylo-glossus  and  stylo-pharyngeus  mus- 
cles to  the  tonsil  and  soft  palate.  It  also  anastomoses  with 
the  superior  palatine  branch  of  the  internal  maxillary  arte- 
ry. The  inferior  pharyngeal  is  a  branch  of  the  external 
carotid. 

The  Arteries  of  the  Tongue  are  the  Lingual.  These  ar- 
teries, on  either  side,  arise  from  the  external  carotid,  run 
forwards  above  and  parallel  with  the  os-hyoides — then  ascend 
to  the  under  surface  of  the  tongue  as  far  as  the  tip,  under 
the  name  of  the  ranine  arteries.  They  give  off  numerous 
branches  in  their  course,  supplying  every  part  of  the  tongue. 

The  mucous  membrane  of  the  mouth  is  principally  sup- 
plied by  the  anterior  and  posterior  palatine,  and  facial  arte- 
ries.    The  gums  by  the  alveolar  and  submental  branches. 

The  Branches  of  the  External  carotid  artery  as  they  arise 
in  numerical  order,  are  as  follows  : 

1.  The  Superior  Thyroid. 

2.  The  Lingual. 

3.  The  Facial. 

4.  The  Inferior  Pharyngeal. 

5.  Occipital. 

6.  Posterior  Auricular. 

7.  Temporal. 

8.  Internal  Maxillary. 

The  internal  maxillary,  bei^'g  the  great  artery  of  the 
mouth,  gives  off  branches  in  the  following  order  : 

1.  A  Tympanic  Brancli, 

2.  Inferior  Dental, 

3.  The  Greater  Meningeal, 

4.  Lesser  Meningeal. 


Origin  behind  the  neck 
of  the  Condyle. 


)  ^10 


94 


BLOOD-VESSELS  OF  THE  MOUTH. 


Origin  between  Ptery- 
goid Muscles. 


Origin  Zygomatic 
fossa. 


Origin  Spheno-Maxil- 
lary  fossa. 


Posterior   Deep   Temporal 

Artery, 
Masseteric^ 
Pterygoid  Arteries. 
Buccal  Artery, 
9.  Anterior  Deep  Temporal, 
10.  Alveolar  or  Superior  Dental, 
Inferior  Orbitar. 
Pterygoid  or  Vidian, 
Superior  Pharyngeal, 
Superior  Palatine,, 
Spbeno-Palatine  Artery. 


11 

12 
13 
14 
15 


THE    VEINS 


The  veins  correspond  so  nearly,  both  in  name  and  course 
with  the  arteries,  that  a  description  of  them  would  be  only 
a  repetition  of  what  has  been  said  ;  suffice  it,  therefore,  to 
observe,  that  there  are  two  veins  to  every  artery,  and  that 
they  are  mostly  collected  into  a  common  trunk  at  the  angle 
of  the  jaw,  called  the  external  jugular  vein,  which  passes 
down  the  neck  in  the  course  of  the  fibres  of  the  platysma 
muscle,  and  terminate  in  the  subclavian  vein  at  the  pos- 
terior edge  of  the  sterno-mastoid  muscle. 

The  office  of  the  veins  is  to  return  the  blood  back  to  the 
heart. 


CHAPTER    SIXTH. 

THE  NERVES  OF  THE  MOUTH. 

The  nerves  supplying  the  mouth  belong  to  the  fifth  pair, 
and  the  portio-dura  of  the  seventh  or  facial  nerve. 

Fig.  41. 


Fia.  41.  The  fifth  nerve  with  its  branches :  a  The  inferior  maxillary  bone ;  5  Pos- 
terior dental  foramen  where  the  inferior  dental  nerve  enters  to  supply-  the  teeth  ; 
c  Inferior  dental  nerve;  d  Gustatory  branch  of  fifth  nerve;  «  Muscular  branch  of 
inferior  maxillary  nerve ;  /  Ophthalmic  nerve ;  g  Infra-orbitar  foramen  where  infra- 
orbitar  nerve  comes  out ;  A  Terminating  branches  of  inferior  dental  nerve;  »  Caa- 
serian  ganglion  ;  j  Internal  view  of  maxillary  sinus ;  k  Superior  maxillary  nerve, 
just  where  it  is  given  off  from  the  ganglion ;  I  Posterior  dental  branch  of  superior 
maxillary  nerve ;  m  Anterior  branch  of  superior  dental  nerve ;  n  Terminating 
branches  of  infra-orbitar  nerve;  o  Nasal  branch  of  ophthalmic  nerve;  p  FroLtal 
branch  of  ophthalmic  nerve. 


96  NERVES   OF  THE   MOUTH. 

The  Fifth  (Trigemini)  are  the  largest  of  the  cranial 
nerveS;,  and  give  sensibility  to  all  the  organs  concerned  in 
the  primary  stages  of  digestion . 

This  nerve  will  also  be  found  to  be  a  compound  nerve, 
having  also  motor  filaments,  and  thereby  giving  motion  as 
well  as  sensation. 

It  is  first  seen  at  the  side  of  the  pons  varolii  near  its  junc- 
tion with,  the  crura-cerebelli — but  its  origin  is  mucb  deeper 
and  further  back. 

It  arises  by  two  fasciculi  which  can  be  traced  down  to  the 
spinal  chord,  and  coming  from  its  anterior  and  posterior 
ends.  It  is  hence  considered  a  spinal  nerve,  and  as  such 
called  the  cranial  spinal  nerve. 

These  two  fasciculi,  the  one  anterior  and  the  other  pos- 
terior, constitute  tlie  fiftli  nerve,  which  consists  of  eighty  or 
one  hundred  filaments  that  pass  forwards  and  outwards  in 
a  canal  formed  of  dura  mater  to  a  depression  on  the  ante- 
rior surface  of  the  petrous  bone. 

At  this  point  it  spreads  into  a  ganglion,  called  the  Cas- 
serian  ganglion,  on  the  under  surface  of  Avhich  is  seen  the 
anterior  root,  but  having  no  connection  with  the  ganglion, 
and  can  be  traced  on,  as  will  be  presently  shown,  to  the 
inferior  maxillary  nerve. 

From  the  ganglion  of  Casscr  proceed  three  primary 
branches,  namely  : 

1.  The  Ophthalmic. 

2.  Superior  Maxillary. 

3.  Inferior  Maxillary  Nerves. 

The  Ophthalmic  Nerve  is  a  short  trunk  that  goes  into  the 
orbit  through  the  foramen  lacerum  superius,  and  divides 
into  three  principal  branches, 

1.  The  Frontal, 

2.  The  Lachrymal,  and 

3.  The  Nasal. 

The   Frontal  passes  along  the  roof  of  the  orbit  to  the 


NERVES  OF  THE  MOUTH.  9Y 

sui)i'a-orMtar  foramen,  tliroiigh  which  it  passes,  and  is  then 
called  the  supra-orbitar  nerve,  and  is  spent  on  the  muscles 
and  integuments  of  the  forehead.  It  gives  off  several 
branches  in  its  course. 

The  Lachrymal,  as  the  term  implies,  goes  to  the  lachry- 
mal gland,  taking  the  outward  direction,  and  sending 
branches  in  its  course  to  the  upper  eye-lid,  conjunctiva  and 
other  parts. 

The  Nasal  takes  its  direction  along  the  inner  side  of  \hQ 
orbit  to  the  anterior  ethmoidal  foramen,  through  which  it 
passes  into  the  cranium,  on  the  upper  surface  of  the  cribri- 
form plate  of  the  ethmoidal  bone,  descends  by  the  side  of 
the  crista-galli  through  a  slit-like  opening  into  the  nose,  and 
there  terminates  by  filaments,  which  are  spent  upon  the 
septum,  mucous  membrane,  anterior  nares,  etc.  It  sends 
off  several  branches  in  its  course,  one  in  particular  to 
the  lenticular  ganglion  at  the  bottom  of  the  eye,  others  to 
the  caruncula  lachrymalis,  lachrymal  sac,  conjunctiva,  etc. , 
but  as  these  do  not  belong  to  the  mouth  and  dental  appa- 
ratus, we  will  pass  to  the  second  great  division  of  the  fifth, 

THE  SUPERIOR  MAXILLARY  NERVE. 

This  nerve  proceeds  from  the  middle  of  the  Casserian 
ganglion,  passes  through  the  foramen  rotundum  of  the 
sphenoid  bone,  into  the  pterygo-maxillary  fossa  ;  here  it 
enters  the  canal  of  the  floor  of  the  orbit — the  infra-orbitar 
canal,  traverses  its  whole  extent,  and  emerges  on  the  face  at 
the  infra-orbitar  foramen,  where  it  terminates  in  numerous 
filaments  in  the  muscles  and  integuments  of  the  ui')per  lip 
and  cheek. 

The  superior  maxillary  nerve  supplies  the  ujiper  jaw,  and 
gives  off  many  important  branches,  which  are  as  follows  : 

In  the  pterygo-maxillary  fossa  two  branches  descend  to  a 
small  reddish  body  called  the  ganglion  of  Meckel,  or  the 


98  NERVES   OP  THE  MOUTH. 

spheno-palatine  ganglion,  situated  on  the  outer  side  of  tlie 
nasal  or  vertical  plate  of  the  palate  bone. 
From  this  ganglion  proceed  three  branches  : 

1.  An  Inferior,  Descending,  or  Palatine  Nerve. 

2.  An  Internal,  Lateral  Nasal,  or  Spheno-palatine. 

3.  A  Posterior,  Pterygoid,  or  Vidian. 

The  Palatine  Nerve  descends  through  the  posterior  pala- 
tine canal,  comes  out  at  the  posterior  palatine  foramen 
along  with  an  artery  of  the  same  name,  and  supplies  with 
filaments  the  soft  palate,  uvula,  tonsils,  the  roof  of  the 
mouth,  and  the  inner  alveoli  and  gums. 

The  Lateral  Nasal  enters  the  nose  through  the  spheno- 
palatine foramen,  divides  into  several  filaments,  which  enter 
the  raucous  membrane  covering  the  upper  and  lower  turbi- 
nated bones,  and  one  long  branch  can  be  traced  along  the 
septum  nasi  as  far  as  the  foramen  incisivum,  where  it  meets 
the  anterior  palatine  branches  in  a  ganglion  called  the  naso- 
palatine. 

The  Vidian,  or  Pterygoid,  passes  backwards  from  the 
ganglion  of  Meckel  through  the  pterygoid  canal  at  the  root 
of  the  pterygoid  process — then  enters  the  cranium  through 
the  foramen  lacerum  anterius,  and  divides  into  two  branches, 
one  of  which  enters  the  carotid  canal  and  unites  with  the 
sympathetic  branches  of  the  superior  cervical  ganglion — 
thus  connecting  this  ganglion  with  the  ganglion  of  Meckel. 

The  other,  the  proper  vidian  nerve,  enters  the  vidian  for- 
amen or  hiatus  fallopii  on  the  petrous  bone,  joins  the  portio- 
dura  nerve,  accompanies  this  as  far  as  the  back  part  of  the 
tympanum,  then  leaves  it,  enters  the  cavity  of  the  tym- 
panum, and  receives  here  the  name  of  Chorda  Tympani.  It 
leaves  this  cavity,  after  supplying  the  several  parts,  by  the 
glenoid  fissure,  now  joins  the  gustatory  nerve,  continues 
with  it  to  the  submaxillary  gland,  where  it  parts  and  is  lost 
in  the  submaxillary  ganglion,  situated  at  the  posterior  part 
of  the  submaxillary  gland. 


NERVES  OP  THE  MOUTH.  99 

This  exceedingly  intricate  course  of  the  vidian  nerve  is 
interesting  from  the  number  of  communications  which  it 
establishes  between  different  and  distant  parts,  for  it  unites 
the  ganglion  of  Meckel  with  the  superior  cervical  ganglion 
of  the  sympathetic,  and  both  with  the  submaxillary  gan- 
glion— it  also  connects  the  superior  and  inferior  maxillary 
nerves  to  one  another  and  the  portio-dura. 

The  Siqoerior  3IaxiUary  Nerve  gives  off  next  in  the  sphe- 
no-maxillary  fossa : 

1.  The  Orbital. 

2.  The  Posterior  Dental  Nerve. 

The  Orbital  enters  the  orbit  through  the  spheno-maxillary 
fissure,  and  then  sends  off  a  ntdlar  and  temjporal  branch, 
which  pass  out  through  the  malar  bone,  the  first  supplying 
the  cheek,  the  latter  accompanying  the  temporal  artery  to 
the  integuments  of  the  side  of  the  head. 

The  Posterior  Dental  Nerves,  three  or  four  in  number, 
descend  on  the  tuberosity  of  the  superior  maxillary  bone, 
and  enter  the  posterior  dental  canals  to  supply  the  molar 
teeth  ;  one  branch  penetrates  the  antrum  and  courses  along 
the  outer  wall,  anastomosing  with  the  anterior  dental 
nerves — while  another  runs  along  the  alveolar  border  sup- 
plying the  gums. 

The  superior  maxillary  nerve  now  enters  the  infra-orbitar 
canal,  and  becomes  the  infra-orbitar  nerve,  which  is  its  ter- 
minating branch. 

The  Infra-Orbitar  nerve  comes  from  behind  forwards 
through  the  canal  of  the  same  name,  and  gives  off  no  branch 
until  it  arrives  at  the  forepart,  where  it  sends  down  along 
the  front  of  the  maxillary  sinus  in  the  anterior  dental  canal 
the  anterior  dental  nerve,  which  divides  so  as  to  supply  the 
incisors,  cuspidati  and  bicuspids,  also  the  mucous  lining 
membrane  of  the  antrum. 


100  NERVES  OF  THE  MOUTH. 

This  nerve  noAv  emerges,  as  before  mentioned_,  at  the  in- 
fra-orbitar  foramen,  between  the  levator  labii  superioris 
alreque  nasi  and  levator  angnli  muscles,  dividing  here  into 
many  branches,  some  of  which  ascend  to  the  nose  and  eye- 
lids, others  pass  downwards  and  outwards  to  the  lip  and 
cheek,  anastomosing  with  the  nasal  branch  of  the  ophthal- 
mic and  the  facial  branches  of  the  portio-dura. 

INFERIOR   MAXILLARY   NERVE. 

This  nerve  forms  the  third  great  division  of  the  fifth.  It 
is  the  largest  branch,  and  passes  from  the  ganglion  of  Cas- 
ser  through  the  foramen  ovale  of  the  sphenoid  bone  to  the 
zygomatic  fossa. 

This  nerve  as  stated,  is  united  to  the  anterior  or  motor 
root,  which  come  together  on  the  outside  of  the  foramen 
ovale,  then  in  the  zygomatic  fossa,  the  inferior  maxillary 
nerve  divides  into  two  branches  : 

1.  An  External,  or  Superior. 

2.  An  Internal,  or  Inferior. 

The  External  is  the  motor  branch,  and  gives  off  the  fol- 
lowing filaments  to  the  several  muscles  : 

1.  3Iassete7'ic,   crossing   the   Sigmoid   notch   to   the 

Masseter  Muscle. 

2.  Temporal,   Anterior  and   Posterior  Deep  to   the 

Temporal  Muscle  and  Fascia,  &c. 

3.  Buccal  J  to  the  Buccinator,  &c. 

4.  Pterygoid,  to  the  Pterygoid  Muscles. 

The  Internal  division  of  the  inferior  maxillary  nerve  con- 
sists of  three  branches,  all  of  which  give  sensation,  and  are: 

1.  The  Anterior  Auricular. 

2.  The  Gustatory. 

3.  The  Inferior  Dental. 

The  Anterior  Auricular  passes  behind  the  neck  of  the 


I 


NERVES  OF  THE  MOUTH.  101 

lower  jaw  and  in  front  of  the  meatus  of  tlie  ear,  and  ascends 
through  the  parotid  gland,  over  the  zygoma  along  with  the 
temporal  artery,  and  divides  into  anterior  and  posterior 
branches. 

In  its  course  it  unites  with  the  facial  nerve,  and  supplies 
the  parotid  gland,  the  articulation  of  the  lower  jaw,  the 
meatus,  and  cartilages  of  the  ear  and  side  of  the  head. 

The  Gustatory  Nerve,  immediately  after  its  origin,  sends 
a  branch  to  the  inferior  dental ;  it  then  descends  between 
the  pterygoid  muscles,  where  the  chorda  tympaui  joins  it;  it 
now  23asses  along  the  ramus  of  the  lower  jaw,  covered  by 
the  internal  pterygoid  muscle,  then  above  the  submaxillary 
glands,  and  forwards  above  the  mylo-hyoid  and  between  it 
and  the  liyo-glossus  muscles,  accompanied  by  the  duct  of 
Wharton,  and  finally  ascends  above  the  sublingual  gland 
to  the  lateral,  inferior  and  anterior  parts  of  the  tongue. 

In  its  course,  Mr.  Harrison  enumerates  tlie  following 
branches  as  given  off  by  this  nerve  : 

"First,  one  or  two  small  filaments  to  the  internal  ptery- 
goid muscle.  Second,  several  to  the  tonsils,  to  the  muscles 
of  the  palate,  to  the  upper  part  of  the  pharynx,  and  to  the 
mucous  membrane  of  the  gums.  Thirds  the  chorda  tym- 
pani,  and  some  accompanying  filaments  to  form  a  plexus, 
wliich  supplies  the  submaxillary  gland.  Fourth,  a  few 
branches  which  descend  along  the  hyo-glossus  muscle  to 
communicate  with  the  ninth  or  lingual  nerve.  Fifth,  a  fas- 
ciculus of  nerves  to  the  sublingual  gland  and  to  the  sur- 
rounding mucous  membrane.  Lastly,  at  the  tongue  it  di- 
vides into  several  branches,  some  pass  deep  into  the  tissue 
of  this  organ,  others  along,  firm  and  soft,  rise  towards  its 
surface,  and  are  lost  in  the  mucous  membrane  and  in  a 
small  conical  papilla  near  its  tip." 

The  Inferior  Dental  Nerve  passes  between  the  pterygoid 
muscles,  then  along  the  ramus  of  the  lower  jaw  under  the 


102 


NERVES   OF   THE   MOUTH. 


pterjgoideiis  internus  to  the  posterior  mental  foramen  which 
it  enters  along  with  an  artery  and  vein  ;  it  now  traverses 
the  inferior  dental  canal,  sending  off  twigs  into  all  the  roots 
of  the  molars  and  bicuspids.  Opposite  the  anterior  mental 
foramen  it  divides  into  two  branches,  the  smaller  is  con- 
tinued forward  in  the  substance  of  the  jaw  to  supply  the 
roots  of  the  cuspidati  and  incisors — while  the  larger  comes 
out  at  the  mental  foramen,  is  distributed  to  the  muscles  and 
integuments  of  the  lower  lip,  and,  finally,  communicates 
with  the  facial  nerve. 

The  inferior  dental,  just  as  it  enters  the  posterior  dental 
foramen,  gives  off  the  mylo-liyoid  nerve  ;  this  passes  for- 
wards in  a  groove  of  the  lower  jaw,  and  supplies  the  mylo- 
hyoid, genio-hyoid  and  digastric  muscles. 

THE  FACIAL  NERVE. 


^"'-  ^'^-  The  Portio-dura  of  the 

seventh  or  facial  nerve,  is 
the  last  nerve  to  be  noticed 
as  particularly  belonging 
to  the  mouth. 

The  Facial  Nerve  arises 
from  the  medulla  oblon- 
gata between  the  corpus 
olivare  and  restiforme, 
close  by  the  lower  margin 
of  the  pons  varolii;  it  then 
passes  forwards  and  out- 
wards with  the  portio- 
^  mollis,  to  the  foramen  au- 
ditorium internus,  which  it  enters  and  passes  on  to  the  base 

Fio.  42.  View  of  the  facial  nerve,  or  portio-dura  of  the  seventh  pair  :  a  Trunk  of 
the  facial  nerve  5  6  Ascending  branch  ;  e  Descending  branch  ;  d  Posterior  auricular 
branch ;  e  e  Temporal  branches  ;  //Malar  branches  ;  g  g  Inferior  maxillary  branches ; 
h  Posterior  or  great  occipital  nerve  ;  t"  Terminal  branches  of  the  inferior  dental  nerve ; 
J  Terminal  branches  of  infra-orbitar  nerve ;  k  Ic  Supra-orbitar  nerve  and  its  branches ; 
I  Orbicularis  oris;  m  Zjgomaticus  major;  n  Zj-gomaticus  minor;  o  Levator  labii 
superioris  alaeque  nasi;  p  Orbicularis  palpebrarum;  q  Depressor  anguli  oris. 


NERVES  OF  THE  MOUTH.  103 

of  this  opening  ;  here  these  two  nerves  separate,  the  mollis 
going  to  the  labyrinth  of  the  ear — while  the  facial  enters 
the  aqueduct  of  Fallopius,  where  it  is  joined  by  the  vidian  ; 
it  then  goes  in  a  curved  direction  outwards  and  backwards 
behind  the  tympanum,  where  it  parts  with  the  vidian, 
and  proceeds  on  to  the  stylo-mastoid  foramen,  at  which  it 
emerges.     At  this  point  it  sends  off  three  small  branches : 

1.  The  Posterior  Auricular. 

2.  The  Stylo-Hyoid. 

3.  The  Digastric. 

The  Posterior  Auricular  ascends  behind  the  ear,  crosses 
the  mastoid  process  to  the  occipito-frontalis  muscle. 

The  Stylo-Hyoid  is  distributed  to  the  stylo-hyoid  muscle. 

The  Digastric  is  distributed  to  the  posterior  belly  of  the 
digastric  muscle. 

The  facial  nerve  being  deeply  imbedded  in  the  substance 
of  the  parotid  gland,  divides  into  two  branches,  the  one  is 
superior,  the  other  inferior ;  these  two  have  frequent  unions 
called  the  pes  anserinus  or  parotidean  plexus,  and  send 
branches  to  the  whole  of  the  side  of  the  face. 

The  upper  branch,  called  the  temporo-facial,  ascends  in 
front  of  the  ear  upon  the  zygoma,  accompanies  the  temporal 
artery  and  its  branches,  supplying  the  side  of  the  head,  ear 
and  forehead,  and  anastomosing  with  the  occipital  and 
supra-orbital  nerves  ;  a  set  of  branches  pass  transversely  to 
the  cheek,  furnishing  the  lower  eyelid,  lips,  side  of  the  nose^ 
and  uniting  with  the  infra-orbitar  nerve. 

The  inferior  or  cervico-facial  branch  descends,  supplying 
the  lower  jaw  and  upper  part  of  the  neck,  giving  off  the  fol- 
lowing branches  : 

1.  The  Maxillary. 

2.  The  Submaxillary. 

3.  The  Cervical. 


104  NERVES  OF  THE  MOUTH. 

The  Maxillary  j^asses  the  ramus  of  the  jaw  and  masseter 
muscle  to  the  lower  lip  and  its  muscles. 

The  SuhmaxiUary  courses  the  base  of  the  lower  jaw,  sup- 
plying the  muscles  which  arise  from  this  part,  and  both 
anastomosing  with  the  mental  nerve. 

The  Cervical  are  long  and  numerous,  and  go  to  the  pla- 
tysma  and  superficial  muscles  of  the  neck,  uniting  with 
branches  from  the  cervical  plexus. 

The  facial  is  the  great  motor  nerve  of  the  face.  Mr.  Bell 
calls  it  a  respiratory,  and  thinks  it  chiefly  concerned  in  ex- 
pressing the  passions. 

In  consequence  of  the  numerous  communications  which 
this  nerve  has  with  other  nerves,  the  name  of  Sympatheticus 
Minor  has  been  given  to  it  by  some  anatomists. 

Having  now  very  briefly  described  the  anatomical  ele- 
ments of  the  several  organs  of  the  mouth,  it  may  be  well 
to  notice,  in  conclusion,  the  anatomical  and  physiological 
relations  of  this  cavity. 

ANATOMICAL  RELATIONS  OP  THE  MOUTH. 

The  mouth  has  many  interesting  anatomical  relations 
with  the  rest  of  the  body^  a  few  of  which  it  may  be  well  to 
mention. 

By  means  of  its  lining  mucous  membrane  it  is  connected 
through  similar  continuity  of  structure  with  the  stomach 
and  the  whole  of  the  intestinal  canal,  etc. 

Disease  still  further  establishes  this  structural  relation. 
Inflammation,  ulceration,  or  any  other  anatomical  change 
in  the  stomach  or  intestines  is  felt  and  reported  on  the 
tongue,  gums  and  other  parts  of  the  mouth,  showing  the 
sympathy  and  the  close  anatomical  relationship  of  these 
several  parts. 

The  mouth  is  also  connected  by  the  same  mucous  mem- 


I 


NERVES  OF  THE  MOUTH.  105 

brane  witli  the  organs  of  respiration  by  being  continued 
down  into  the  larynx^  trachea  and  bronchia. 

By  the  fifth  pair  of  nerves,  the  mouth,  and  especially 
the  dental  apparatus,  has  a  most  important  relation  with 
the  brain,  nervous  system^  and  all  the  parts  dependent  on 
them. 

Simple  irritation  from  teething  has  frequently  thrown 
children  into  convulsions — and  in  adults  tooth-ache  often 
creates  extreme  irritability  of  the  whole  nervous  system. 
But  it  is  not  necessary  to  dwell  here  on  the  morbid 
sympathies  of  the  mouth  with  other  parts  of  the  body,  as 
the  author  will  have  occasion  to  do  this  in  other  parts  of 
the  work.  It  will  be  well,  however,  to  mention  in  this 
place  that  there  is  a  general  anatomical  relation  of  the 
mouth  with  the  rest  of  the  body,  by  means  of  the  blood- 
vessels and  cellular  tissue. 

These  latter  are  the  most  pervading  general  elements 
of  the  body;  they  are  found  every  where  connecting  and 
binding  together  all  the  organs  in  one  great  and  common 
family,  and  in  this  manner  the  mouth  is  related  to  and 
forms  an  essential  link  in  this  natiy*al  chain. 

PHYSIOLOGICAL  RELATIONS. 

The  mouth  has  been  shown  to  consist,  not  only  of  a  great 
variety  of  parts,  but,  also,  that  it  has  an  equally  great 
variety  of  functions. 

The  functions  of  the  mouth  have  been  stated  to  be  those 
of  prehension,  mastication,  insalivation  and  deglutition. 

These  functions,  it  has  been  seen,  are  all  closely  related 
the  one  with  the  other,  and  mutually  dependent ;  and  how 
beautiful  is  the  harmony  of  action  as  well  as  its  regular  and 
orderly  succession.  We  see  in  the  first  place  the  prehensile 
instruments  laying  hold  of  and  introducing  the  food  into 
the  mouth — then  the  organs  of  mastication,  the  teeth  and 
upper   and   lower  jaw   bones,  put   into   operation    by   the 


106  NERVES  OF  THE  MOUTH. 

temporal,  masseter  and  pterygoid  muscles,  grind  it  down 
into  minute  portions,  wliicli  at  the  same  time  is  formed  into 
a  bolus  by  being  mixed  with  the  salivary  fluids,  furnished 
by  the  parotid,  submaxillary  and  sublingual  glands  ;  then 
it  is  taken  by  the  organs  of  deglutition,  namely,  the  tongue, 
palate  and  pharynx,  and  passed  by  these  into  the  esophagus, 
to  be  thence  conducted  into  the  stomach — thus  demonstrat- 
ing the  harmon}^  of  relation  among  the  several  functions 
belonging  to  the  mouth. 

But  the  functional  relation  of  the  mouth  is  no  more  con- 
fined to  itself  than  its  structural  relation ;  the  one  is  equally 
commensurate  with  the  other  ;  and  as  the  structure  of  the 
mouth  has  been  shown  to  be  continuous  with,  and  to  extend 
to  the  most  extreme  parts  of  the  body,  so  we  find  that  the 
functions  of  the  mouth  equally  involve  all  the  great,  gen- 
eral and  leading  functions  of  the  body. 

For  example,  if  the  primary  stages  of  digestion  be  im- 
paired or  improperly  performed  in  the  mouth,  the  whole 
process  of  digestion  must  also  be^  necessarily,  imperfect ; 
the  stomach  will  foim  bad  chyme,  the  intestines  bad  chyle, 
and  this  impure  fluid  ^\«ll  go  to  the  heart  and  lungs  where 
bad  blood  will  be  formed,  and  as  a  necessary  consequence, 
the  functions  of  circulation,  respiration  and  inervation,  will 
also  become  implicated,  and  in  this  way  we  see,  that  by 
disturbing  only  one  link,  at  once  the  brotherhood  of  the 
great  functional  chain  becomes  broken. 

Again,  the  mouth  is  intimately  related  with  the  intel- 
lectual functions  ;  as  for  instance,  that  of  speech.  Who 
docs  not  know  that  when  any  of  the  teeth  are  wanting,  the 
palate  cleft,  or  there  is  a  hare-lip,  how  much  the  speech  is 
impaired?  And  so  with  all  the  other  functions  of  the 
body,  the  relation  between  them  and  the  mouth,  and  the 
mutual  dependence  of  each  on  the  other,  is  equally  de- 
monstrable. 


1 


NERVES  OF  THE  MOUTH.  107 

The  Formation  and  Progress  of  tlie  teeth,  might  seem  to 
come  most  naturally  under  consideration  in  this  place,  but 
we  defer  their  description  for  the  next  chapter,  to  which  the 
reader  is  referred. 


CHAPTER     SEVENTH. 

ORIGIN   AND  FORMATION  OF  THE  TEETH. 

Of  all  the  ojjerations  of  the  anima,l  economy,  none  are 
more  curious  or  interesting  than  that  which  is  concerned  in 
the  jjroduction  of  the  teeth.  In  obedience  to  certain  devel- 
opmental laws,  established  by  an  all-wise  Creator,  it  is  car- 
ried on  from  about  the  sixth  or  seventh  week  of  intra-uterine 
existence,  with  the  nicest  and  most  wonderful  regularity, 
until  completed,  and  so  secretly  conducted  as  to  prevent  the 
closest  scrutiny  from  detecting  the  manner  in  which  it  is 
effected  ;  enough,  however,  is  ascertained  from  its  progres- 
sive results  to  excite  in  the  mind  of  the  physiologist  the 
highest  admiration. 

From  small  mucous  pajnlla^,  observable  at  a  very  early 
period  of  fetal  life,  situated  in  a  groove,  lined  with  mucous 
membrane,  and  running  along  the  alveolar  border  of  each 
jaw,  the  teeth  are  gradually  developed.  As  they  increase 
in  size,  they  assume  the  shape  of  the  crowns  of  the  several 
classes  of  teeth  they  are  respectively  destined  to  produce. 
Having  arrived  at  this  stage  of  their  formation,  they  now 
begin  to  dentinify  first  upon  the  cutting  edges  of  the  inci- 
sors, the  apices  of  the  cuspidati,  bicuspids  and  eminences 
of  the  molars  ;  from  thence  the  process  is  continued  over  the 
whole  surfjice  of  their  crowns,  until  the}'^  become  invested 
in  a  complete  layer  of  dentine  ;  and  so  on,  layer  after  layer 
is  formed,  one  within  the  other,  until  the  process  of  solidifi- 
cation is  completed.  But  before  it  has  progressed  very  far. 
the  enamel  and  roots  of  the  teeth  begin  to  form,  and  the- 
formative  operations,  including  dentition,  are  gone  through 
with  previously  to  the  completion  of  the  dentification  of  the 
pulps. 


I 


ORIGIN   AND   FORMATION   OP  THE  TEETH.  109 

In  the  meantime^,  and  in  anticipation  of  tlie  loss  of  the 
temporary  teeth,  a  second  set  is  forming,  and  as  the  teeth 
of  the  one  are  removed,  they  are  promptly  replaced  by  those 
of  the  other.  Thus,  by  this  beautiful  and  most  admirable 
provision  of  nature,  the  first  set  of  teeth  intended  to  sub- 
serve the  wants  only  of  childhood,  while  the  jaws  are  too 
small  for  the  reception  of  such  as  are  required  for  an  adult, 
are  removed^  and  replaced  by  a  larger,  stronger  and  more 
numerous  set. 

The  elder  writers,  regarding  a  knowledge  of  the  early 
stages  of  the  development  of  the  teeth  as  not  of  much  im- 
portance, paid  little  attention  to  the  subject,  and  hence,  this 
most  curious  and  interesting  department  of  developmental 
anatomy  has  remained,  until  recently,  measurably  unculti- 
vated. EusTACHius,  we  believe,  was  the  first  to  notice  the 
■  losition  and  arrangement  of  the  teeth  in  the  jaws  previous- 
ly to  their  eruption.  But  his  researches  were  confined  to 
the  examination  of  the  jaws  after  birth,  at  which  j^eriod  he 
speaks  of  having  discovered,  by  dissection,  the  incisors, 
( usjiidati  and  three  molars  on  each  side  in  each  jaw,  partly 
in  a  gelatinous  and  partly  in  a  solidified  condition.  He  also 
discovered  the  incisors  and  cuspidati  of  the  permanent  set 
behind  the  first.  ' 

Eustachius  wrote  in  1563,  and  nineteen  years  later,  Ur- 
BiAN  Hemard,  a  French  anatomist  and  surgeon,  although 
unacquainted  with  the  work  of  the  former,  gave  a  very 
similar  description  of  the  situation  of  the  crowns  of  the  in- 
cisors and  cuspidati  of  both  sets  in  the  jaws  of  an  infant  at 
birth.  He  represents  them  as  partly  bony  and  partly  mu- 
cilaginous. He  also  discovered  the  bicuspids,  but  he  was 
unable  to  find  the  molars  at  so  early  a  period  as  birth. 

The  researches  of  Albinus  threw  no  additional  light  upon 
the  manner  of  the  formation  of  the  teeth,  and  little  was 
known  concerning  the  earlier  stages  of  the  development  of 
tliese  organs  until  the  time  of  John  Hunter,  who  informs 
us  that  in  the  alveoli  of  a  fetus  of  three  or  four  months, 
•four  or  five  pulpy  substances,  not  very  distinct,  are  seen." 


110  ORIGIN   AND   FORMATION   OF   THE  TEETH. 

But  he  says,  ''about  the  fifth  month  the  alveolar  cavities 
are  more  perfect  and  the  pulps  of  the  teeth  more  distinct," 
and  that  the  anterior  are  more  advanced  than  those  further 
back  in  the  jaws.  It  is  at  about  this  age  that  he  dates  the 
commencement  of  dentinification  on  the  edge  of  the  tempo- 
rary incisors.  The  situation  and  arrangement  of  the  teeth 
in  the  jaws  at  this  period  he  describes  very  accurately.  At 
the  expiration  of  the  sixth  or  seventh  month,  he  represents 
the  first  permanent  molar  as  having  begun  to  be  formed  in 
the  tubercle  of  the  upper  jaw,  and  "under  and  on  the  in- 
side of  the  coronoid  i^rocess  in  the  lower,"  and  he  states, 
that  the  pulps  of  the  permanent  central  incisors  begin  to 
appear  in  a  fetus  of  "seven  or  eight  months,"  and  to  den- 
tinify  "five  or  six  months  after  birth."  The  pulps  of  the 
permanent  lateral  incisors  and  cuspidati  he  says  begin  to  be 
formed  soon  after  birth  ;  the  first  bicuspids  about  the  fifth 
or  sixth  year,  the  second  bicuspids  and  molars  the  sixth  or 
seventh,  and  the  dentes  sapientias  about  the  twelfth  year. 

Although  Mr.  Hunter  gives  a  more  minute  and  accurate 
description  of  the  progress  of  the  formation  and  arrange- 
ment of  the  teeth  in  the  jaws  previously  to  their  erujDtion 
than  any  previous  writer,  yet  with  regard  to  their  origin 
and  appearance  during  the  earlier  stages  of  their  develop- 
ment, it  is  unsatisfactory.  Nor  do  the  researches  of  Jour- 
dain,  Blake,  Fox,  Cuvier,  Serres,  Delabarre  and  other  wri- 
ters, throw  much  additional  light  upon  the  subject.  In  fact, 
they  could  not,  as  their  researches  do  not  seem  to  have  been 
commenced  at  periods  sufiiciently  early  in  fetal  subjects  ; 
and  even  from  the  time  when  they  were  first  instituted,  the 
progress  of  the  organs  do  not  appear  to  have  been  traced 
through  the  subsequent  stages  of  their  formation  with  the 
requisite  degree  of  care  and  accuracy.  It  is  not,  therefore, 
necessary  to  notice  the  description  given  by  these  authors  of 
the  progress  of  the  formation  of  the  teeth,  although  it  may 
not  be  amiss  to  state  here,  that  Dr.  Blake  describes  the 
rudiments  of  the  permanent  as  originating  from  the  sacs  of 
the  temporary,  and  that  this  supposed  discovery  has  been 


ORiaiN   AND   FORMATION   OF    THE   TEETH.  Ill 

confirmed  by  almost  every  subsequent  writer  upon  the  sub- 
ject.* Indeed,  until  c^uite  recently,  this  has  been  the  pre- 
vailing opinion,  and  their  progress,  step  by  step,  from  the 
time  when  the  rudiments  of  these  teeth  are  apparently  given 
off  as  small  bud-like  processes  from  the  sacs  of  the  tempo- 
lary,  is  traced  with  a  degree  of  minuteness  by  Mr.  Thomas 
Bell_,  that  would  seem  to  preclude  the  possibility  of  decep- 
tion. This  last  named  gentleman  describes  the  process  as 
commencing  at  a  very  early  period  of  the  formation  of  the 
temporary  teeth,  and  as  first  perceivable  ''^in  a  small  thick- 
ening on  one  side  of  the  parent  sac,"  which,  "gradually 
increasing,"  becomes  ''more  and  more  circumscribed,  until 
it  at  length  assumes  a  distinct  form,  though  still  connected 
with  it  by  a  peduncle,  which,"  he  says,  "is  nothing  more 
than  a  j)rocess  of  the  investing  sac."  "For  a  time^"  con- 
tinues Mr.  Bell,  "the  new  rudiment  is  contained  within  the 
same  alveolus  with  its  parent,  which,  excavated  by  the  ab- 
sorbents for  its  reception,  by  a  process  almost  unparalleled 
in  the  phenomena  of  physiology.  It  is  not  produced  by 
the  pressure  of  the  new  rudiment,  as  is  erroneously  be- 
lieved, but  commences  in  the  cancelli  of  the  new  bone  im- 
mediately within  its  smooth  surface^  tlius  constituting  what 
may  be  termed  a  process  of  anticipation.  The  new  cell 
after  being  sufficiently  excavated,  and  as  the  rudiment  con- 
tinues ,to  increase,  is  gradually  separated  from  the  former 
one,  by  being  more  and  more  deeply  excavated  in  the  sub- 
stance of  the  bone,  and  also  by  the  deposition  of  a  bony 
partition  between  them  ;  and  at  length  the  new  rudiment 
is  shut  up  in  its  proi)er  socket,  though  still  connected  with 
the  temporary  tooth  by  a  chord  or  process  of  the  capsule  al- 
ready described,  which  has  in  the  meantime  been  gradually 
attenuated  and  elongated. f" 


*  It  is  said,  but  with  how  much  truth  the  author  is  unable  to  say,  that  this  sup- 
posed discover}'  was  made  about  twenty  years  before  the  publication  of  Dr.  Blake's 
Inaugural  Dissertation,  by  a  French  dentist  by  the  name  of  Herbert. 

t  This  chord  has  been  noticed  and  minutely  described  by  several  other  writers. 
Delabarre  calls  it  the  appendage  of  the  dental  matrix,  and  traces  it  through  what 


112  ORIGIN    AND   FORMATION   OF   THE   TEETH. 

Now  it  would  hardly  seem  possible  for  a  man  of  Mr, 
Bell's  accuracy  of  observation,  after  having  investigated 
the  subject  as  closely  and  thoroughly  as  he  must  have  done, 
to  have  enabled  him  to  describe  so  minutely  the  various 
stages  of  the  progress  of  the  development  of  the  permanent 
teeth,  to  have  mistaken  their  origin,  and  that  he  has,  would 
appear,  by  subsequent  researches,  to  be  rendered  certain.  I 
allude  to  those  of  Arnold  and  Goodsir. 
-  The  last  named  author  has  traced  the  progress  of  the 
teeth,  almost  from  the  moment  of  the  appearance  of  the 
germs  of  the  first  set,  as  simple  mucous  papilla?,  until  the 
completion  of  the  second,  and  so  minutely  and  accurately, 
that  little  remains  to  be  done  by  future  anatomists,  for  the 
perfection  of  this  branch  of  odontology. 

Relying  upon  the  accuracy  of  his  researches,  which  are 
described,  at  length,  in  the  Edinburg  Medical  and  Surgical 
Journal,  for  January  1st,  1839,  we  shall  proceed  to  give  a 
brief  summary  of  their  result,  as  the  length  of  the  paper  is 
such  as  to  i^reclude  its  insertion  entire. 

Fig.  43.  They  were  commenced  in  an  em- 

bryo at  the  sixth  week,  at  which  pe- 
riod a  deep  groove,,  formed  by  two 
semi-circular  folds,  extending  around 
each  jaw,  is  perceived,  lined  with 
mucous  membrane  and  as  this  gradu- 
ally widens  from  behind  forwards,  a 
ridge,  commencing  posteriorly  and  running  in  the  same 
direction,  rises  from  its  floor,  and  divides  the  original  groove 
into  two  others  ;  the  outer  one  forming  the  duplicature  of 
mucous  membrane  from  the  inside  of  tlie  lip  to  the  outside 
of  the  alveolar  process,  tlie  inner  one  constituting  what  may 

is  usually  denominated  the  alveolo-dcntal  canal,  vrhich  he  designates  by  the  name 
of  iVer  dentif,  to  the  surface  of  the  gum  behind  the  temporary  teeth.  He  also  states 
that  it  is  hollow,  and  when  he  first  described  it  in  his  thesis  of  reception  in  1806,  it 
had  not  been  noticed  by  any  other  writer. 

Fig.  43.     Upper  jaw  of  human  fetus  at    sixth   week  j  a  The  lip;  b  Primitive- 
dental  groove. 


i 


ORIGIN   AND   FORMATION   OF  THE   TEETH.  113 

be  very  properly  denominated  the  primitive  dental  groove,  as 
the  germs  of  the  teeth  appear  in  it. 

The  inner  lip  of  the  inner  groove  is  formed  by  the  outer 
edge  of  a  semi-circular  lobe  which  is  to  constitute  the  future 
palate.  By  the  seventh  week  after  conception,  the  germ  of  ^'|^\''^il 
the  first  temporary  molar  in  the  upper  jaw  may  be  seen  in 
i\ie  primitive  dental  groove,  rising  np  from  the  mucous  mem- 
brane lining  its  floor  in  the  form  of  a  simple  free  granular 
papilla,  of  an  ovoidal  shape — the  long  diameter  of  which  is 
anterio-posterior.    By  the  ^^(J-  ^^-  ;' ' 

eight  week,  another  pa- 
pilla, of  a  rounded  and 
granular  form  is  observa- 
ble_,  between  the  middle 
and  anterior  curve  of  the 
ridge,  on  the  floor  of  the 
same  groove,  which  is  the 
rudiment  of  the  tempora- 
ry cuspidatus.  During 
the  ninth  week,  the  germs 
of  the  incisors — the  cen- 
tral first,  and    soon  after 

the  lateral — make  their  appearance  in  the  form  also  of  mu- 
cous papillae.  During  the  tenth  week  the  sides  of  the  groove 
before  and  behind  the  anterior  molar  papilla  have  been  grad- 
ually approaching  each  other  and  processes  from  its  sides 
are  sent  off,  from  before  and  behind  this  germ,  which  meet 
and  enclose  it  in  a  follicle.  In  the  meantime  a  similar  folli- 
cle is  gradually  forming  around  the  cuspid  germ.  Towards 
the  end  of  the  tenth  week,  the  papilla  of  the  second  or 
posterior  temporary  molar  shows  itself. 

Tlie  papilhe  of  the  incisor  teeth,  which,  up  to  this  time, 
have  advanced  very  slowly,  now  begin  to  increase  more  rap- 

FiG.  44.  Lower  jaws  of  human  fetus  at  the  ninth  week  of  intra-utcrinc  life, 
taken  from  KiJlUker;  magnified  nine  diameters  :  a  Tongue  thrown  back;  6  Right 
half  of  the  lip  depressed  ;  h  Left  half  cut  off ;  c  Outer  alveolar  wall ;  d  Inner  alve- 
olar wall;  e  Papilla  of  the  first  molar;  /  Papilla  of  the  cuspidatus  ;  g  Of  the  se- 
cond incisor ;  h  Of  the  first  incisor ;  i  Folds  where  the  ductui  riviniani  subsequent- 
Iv  enter. 


114  ORIGIN   AND   FORMATION   OF   THE  TEETH. 

idly,  and  during  the  eleventh  and  twelfth  weeks,  processes 
are  sent  off  from  the  outer  and  inner  walls  of  the  groove, 
forming  for  each  a  distinct  follicle,  and  while  the  papillae  of 
the  cuspidatus  and  first  molar  are  now  undergoing  little 
change,  that  of  the  second  molar  is  gradually  increasing. 
During  the  thirteenth  week  a  follicle  is  formed  for  it^  and  a 
gradual  change  takes  place  in  the  different  papilla3  ;  each 
begins  now  to  assume  a  particular  shape — the  incisors,  that 
of  the  future  teeth — the  cuspidati  "become  simple  cones," — 
the  molars  "become  flattened  transversely."  The  papillae 
now  "grow  faster  than  the  follicles,  so  that  the  former  pro- 
trude from  the  mouths  of  the  latter  while  the  depth  of  the 
latter  varies  directly  as  the  length  of  the  fangs  of  their  fu- 
ture corresponding  teeth."  The  mouths  of  the  follicles,  in 
the  meantime,  are  becoming  more  developed_,  "so  as  to  form 
opercula^  which  correspond  in  some  measure  with  the  shape 
of  the  crowns  of  the  future  teeth."  Of  these,  the  incisor 
follicles  have  two — one  anterior  and  one  posterior — the  first 
larger  than  the  latter  ;  the  cuspidati  follicles  have  three — 
one  external  and  two  internal  ;  the  molar  follicles,  as  many 
as  there  are  eminences  or  tubercles  upon  the  grinding  sur- 
faces of  these  teeth. 

The  outer  and  inner  lips  of  the  primitive  dental  groove 
have  increased  so  much,  that  at  the  fourteenth  week,  they 
meet  and  come  themselves  together  like  two  valves,  so  as  to 
give  the  papilla)  the  appearance  of  receding  back  into  their 
follicles,  and  to  become  almost  wholly  hid  by  their  opercu- 
la.  The  appearance  and  progress  of  the  germs  of  the  lower 
teeth  and  their  follicles  are  nearly  precisely  similar  to  those 
of  the  upper,  though  they  do  not  appear  at  quite  so  early  a 
period. 

At  the  epoch  last  mentioned_,  the  primitive  dental  groove 
is  situated  on  a  higher  level  tlian  at  first,  contains  the  germs 
and  follicles  of  the  ten  temporary  teeth,  and  "may  now  be 
more  properly  denominated  the  secondary  dental  groove," 
for  it  is  about  this  time,  that  provision  is  made  for  the  pro- 
duction of  the  ten  anterior  permanent  teeth.     It  consists  in 


ORIGIN   AND   FORMATION   OF  THE  TEETH.  115 

the  appearance  of  a  depression  of  a  crescent  shape  immedi- 
ately behind  the  inner  opercula  of  the  follicles  ;  first,  of  the 
central  incisors,  next  of  the  laterals,  then  of  the  cuspids,  af- 
terwards of  the  first  bicuspids.  The  opercula^  in  the  mean- 
time, close  the  mouths  of  the  follicles,  but  without  adher- 
ing ;  beginning  with  the  central,  then  with  the  lateral,  the 
cuspidati,  and  ending  with  the  second  molars.  The  secon- 
dary groove  is  now. soon  closed  by  the  approach  and  adhe- 
sion of  its  lips  and  walls,  commencing  from  behind  and 
proceeding  forwards — changing  the  follicles  into  sacs — the 
papillae  into  the  pulps  of  the  temporary  teeth,  and  the  cres- 
cent-formed depressions  into  ^^ cavities  of  reserve"  from 
which  the  pulps  and  sacs  of  the  teeth  of  replacement  are  de- 
veloped. The  primitive  dental  groove,  which,  by  this  time, 
has  extended  itself  back  of  the  second  temporary  molar, 
still  retains  its  original  appearance  ;  it  has  a  grayish  yellow 
color,  and  its  edges  continue  "smooth  for  a  fortnight  or 
three  weeks  longer"  for  the  development  of  the  papilla  and 
follicle"  of  the  first  permanent  molar. 

The  papillae  of  the  temporary  teeth  are  now  gradually 
moulded  into  the  shape  of  the  teeth  they  are  destined  to 
form  :  the  pulps  of  the  upper  molars  are  perforated  by  three 
canals,  and  the  lower  by  two,  which  penetrate  to  their  cen- 
tre. The  primary  base  is  divided  into  an  equal  number  of 
secondary  bases,  from  which  the  roots  of  the  future  teeth 
are  gradually  developed.  An  intervening  space  is  now 
formed  between  the  pulps  and  the  sacs,  by  the  more  rapid 
growth  of  the  latter  than  the  former,  "in  which  is  depos- 
ited a  gelatinous  granular  substance,  at  first  small  in  quan- 
tity, and  adherent  only  to  the  proximal  surfaces  of  the  sacs, 
but  ultimately,  about  the  fifth  month,  closely  and  intimate- 
ly attached  to  the  whole  interior  of  these  organs^  except  for 
a  small  space  of  equal  breadth,  all  round  the  base  of  the 
pulps,  which  space  retains  the  original  gray  color  of  tlie  in- 
ner membrane  of  the  follicle,  and  as  the  primary  base  of  the 
pulp  becomes  perforated  by  the  canals  formei'ly  mentioned, 
the  granular  matter  sends  processes  into  them,  wliich  ad- 


116  ORIGIN   AND   FORMATION   OF  THE  TEETH. 

liering*  to  tlie  sac,  reserve  the  narrow  space  described  above, 
between  themselves  and  the  secondary  bases.  These  pro- 
cesses of  granular  matter  do  not  meet  across  the  canals,  but 
disappear  near  their  point  of  junction."  The  granular 
matter,  although  not  adhering  to  the  pulp,  is  exactly 
moulded  to  all  its  eminences  and  depressions. 

The  outer  membrane  of  the  sac,  according  to  Mr.  Good- 
sir,  is  supplied  with  blood  from  small  twigs  sent  off  by  each 
branch  of  the  dental  artery  at  the  fundus  of  its  destined 
sac,  and  from  the  arteries  of  the  gums,  which  inosculate 
with  each  other,  and  then  ramify  the  ^'true"  (inner)  mem- 
brane. 

The  follicle  of  the  first  permanent  molar  closes  about  this 
time,  and  has  granular  matter  deposited  in  its  sac,  and  by 
the  non-adhesion  of  the  walls  of  the  secondary  groove,  a 
cavity  appears  below  the  sac  of  this  tooth,  and  from  the 
lining  mucous  membrane  the  second  and  third  molar  teeth 
derive  their  origin. 

But  previously  to  tliis  period^  the  apices  and  eminences  of 
the  temporary  teeth  have  become  vascular,  and  now  earthy 
salts  begin  to  be  deposited.  Simultaneously  with  this  pro- 
cess, the  inner  surface  of  the  granular  matter  is  absorbed, 
and  after  a  while  becomes  so  thin  as  to  render  the  subjacent 
vascularity  apparent.  This  goes  on,  and  by  the  time  a  layer 
of  dentine  has  formed  over  the  whole  surface  of  the  pulp  and 
reached  its  base,  no  remains  of  it  are  left. 

The  cavities  of  ^reserve  have  been  gradually  receding  and 
assuming  a  position  behind  the  temporary  teeth,  the  distal 
extremities  of  the  anterior  ones  begin  to  distend  about  the 
fifth  montli,  and  it  is  here  that  the  germs  of  the  teeth  of 
replacement  first  appear,  and  are  indicated  by  a  bulging  up 
or  folding  of  this  portion  of  these  cavities.  These  soon  ac- 
quire tlie  appearance  of  dental  pulps,  and  the  mouths  of  the 
cavities  gradually  become  obliterated. 

By  the  sixth  month,  bony  septa  have  formed  across  the 
alveolar  groove,  and  niches  are  now  formed  on  the  posterior 
walls  of  the  alveoli  for  the  sacs  of  the  permanent  teeth. 


ORIGIN   AND   FORMATION   OF   THE  TEETH.  117 

The  sac  of  the  first  permanent  molar  remains  up  to  the 
eighth,  and  even  the  ninth  month,  imbedded  in  the  maxil- 
lary tuberosity.  The  roots  of  the  temporary  incisors,  at  or 
a  little  before  birth,  begin  to  be  formed,  and  in  the  accom- 
plishment of  Avhich,  says  Mr.  Goodsir,  ''three  cotempora- 
neous  actions  are  emjDloyed,  viz.  the  lengthening  of  the 
pulp  ;  the  deposition  of  tooth  substance  upon  it ;  and  the 
adhesion  of  the  latter  of  that  portion  of  the  inner  sac  which 
is  opposite  to  it."  By  this  time  the  central  iiwjisors  appear 
through  the  gum,  the  jaw  has  lengthened  so  much,  that  the 
first  permanent  molar  begins  to  assume  its  proper  position 
in  the  posterior  part  of  the  alveolar  arch.  The  sacs  of  the 
permanent  teeth  continue  to  recede  during  the  advance  of 
the  temporary  teeth  and  their  sockets  to  acquire  their  per- 
fect state,  and  to  insinuate  themselves  between  the  sacs  of 
the  former  until  they  are  only  connected  by  their  proximal 
extremities,  through  tlie  alveolo-dental  foramina  or  itinera 
dentium  of  Delabarre. 

The  vessels  which  go  to  the  sacs  of  the  permanent  teeth 
are  derived,  first,  from  the  gums,  but  they  ultimately,  re- 
ceive vessels  from  the  temporary  sacs,  which,  uniting  with 
the   others,  eventually  retire  into  permanent  dental  canals. 

The  following  diagram,  taken  from  Groodsir,  exhibits  at 
one  view  the  origin  and  progress  of  the  formation  of  a  tem- 
porary and  its  corresponding  permanent  tooth. 

Fig.  45. 


A 


f§A> 


^    (.' 


Fig.  45.  a  Mucous  membrane  ;  b  Mucous  membrane,  with  a  jjranular  mass  depos- 
ited in  it ;  c  The  pi  imitivo  dental  groove  ;  d  A  papilla  on  the  floor  of  the  groove  ; 


118  ORIGIN   AND   FORMATION   OF   THE   TEETH. 

The  cavity  of  reserve,  behind  the  first  permanent  molar, 
heo-ins  to  lengthen  ahout  the  seventh  or  eighth  month,  a 
papilla  soon  appears  in  its  fundus,  it  then  contracts  and 
sejDarates  from  the  remainder  of  the  cavity,  by  which  means 
a  new  sac  is  formed,  that  of  the  second  permanent  molar. 
As  the  jaw  increases  in  lengthy  it  comes  downwards  and 
forwards.  The  papillas  of  the  wisdom  teeth  (dentes  sapi- 
entife)  form  in  the  remaining  portion  of  the  cavities  of  re- 
serve, which^  in  the  upper  jaw_,  occupy  the  maxillary  tuber- 
osities,, and  in  the  lower,  the  base  of  the  coronoid  processes, 
which  places,  says  Goodsir,  they  do  not  leave  until  the 
nineteenth  or  twentieth  year. 

The  progress  of  the  formation  of  the  three  molar  teeth, 
will  be  seen  in  the  diagram.  Fig.  46,  also  copied  from  Mr. 
Goodsir. 

From  the  foregoing  generalization  of  the  description  given 
by  Mr.  Goodsir  of  the  development  of  the  pulps  and  sacs  of 
the  human  teeth,  it  is  seen,  that  the  papilla  of  the  first 
temporary  molar  makes  its  appearance  at  about  the  seventh 
week  of  embryonic  life  ;  at  the  eighth  week,  the  cuspid  pa- 
pilla is  developed  ;  during  the  ninths  the  papillae  of  the  in- 
cisors make  their  appearance^  and  by  the  end  of  the  tenth 
week,  the  papilla  of  the  second  temporary  molar  may  be 

e  The  papilla  enclosed  in  a  follicle,  and  the  secondary  dental  groove  forming  ;/The 
papilla  assuming  the  shape  of  a  pulp,  the  opercula  forming,  and  a  depression  for  a 
reserve  cavity  behind  the  inner  operculum  ;  g  The  papilla  becomes  a  pulp,  the  fol- 
licle a  sac  by  the  adhesion  of  the  lips  of  the  opercula,  and  the  secondary  dental 
groove  in  the  act  of  closing ;  h  The  secondary  groove  adherent,  except  behind  the 
inner  operculum,  where  it  has  left  a  shut  cavity  of  reserve  for  the  formation  of  the 
pulp  and  sac  of  the  permanent  tooth  ;  t  The  last  change  more  complete  by  the  de- 
position of  the  granular  body,  deposition  of  tooth  substance  commencing;  j  The 
cavity  of  reserve  receding ;  its  bottom,  in  which  the  pulp  is  forming,  dilating ; 
fc  The  cavity  of  reserve  becoming  a  sac  with  a  pulp  at  its  bottom,  and  further  re- 
moved from  the  surface  of  the  gums.  The  temporary  tooth  covered  with  a  layer 
of  bone,  and  the  granular  substance  absorbed ;  ?  The  temporary  tooth  acquiring 
its  root  and  approaching  the  surface  of  the  gums  ;  m  Root  of  the  temporary  tooth 
longer,  and  its  sac  touching  the  surface  of  the  gum ;  n  Eruption  of  temporary 
tooth,  its  sac  again  a  follicle,  and  the  permanent  receding  further  from  the  surface 
of  the  gum  ;  o  Completion  of  temporary  tooth,  free  portion  of  sac  become  the  vas- 
cular margin  of  the  gum,  and  the  permanent  sac  connected  by  a  cord  passing 
through  the  alveolo-dental  canal  or  foramen. 


I 


k 


ORIGIN   AND   FORMATION   OF   THE  TEETH. 


119 


seen.  At  the  end  of  the  fourteenth  week,  the  primitive 
dental  groove,  containing  the  germs  and  follicles  of  the  ten 
temporary  teeth,  and  situated  on  a  higher  level,  becomes 
the  secoudar}'  dental  groove,  from  which  the  papilla  of  the 
teeth  of  replacement  are  furnished.  The  secondary  groove 
assuming  the  form  of  crescent-shaped  depressions  behind 
the  palatine  opercula  of  the  follicles  of  the  temporary  teeth. 
The  cavities  of  reserve  for  the  permanent  teeth  gradually 
recede  and  assume  a  position  behind  the  sacs  of  the  decidu- 
ous teeth.  From  the  distal  extremities  of  these  the  papilla 
of  the  replacing  teeth  are  developed. 

Fig.  46. 


il 


TI 


> 


^1:1 


') 


y^^ 


Fig.  46.  a  The  non-adherent  portion  of  the  primitive  dental  groove  ;  b  The  pa- 
pilla and  follicle  of  the  first  molar  on  the  floor  of  the  non-adherent  portion,  now 
become  a  portion  of  the  secondary  groove;  c  The  papilla  a  pulp,  and  the  follicle  a 
sac,  and  the  lips  of  the  sccondarj  groove  adhering,  so  that  the  latter  has  become 
the  posterior  or  great  cavit}'  of  reserve ;  d  The  sac  of  the  first  molar  increased  in 
size,  advancing  into  the  coronoid  process  or  maxillary  tuberosity,  and  the  cavity  of 
reserve  lengthened;  e  The  sac  of  the  first  molar  returned  by  the  same  path  to  its 
former  position,  and  the  cavity  of  reserve  shortened  ;/ The  cavity  of  reserve  send- 
ing backwards  the  sac  of  the  second  molar ;  g  The  sac  of  the  second  molar  ad- 
vanced into  the  coronoid  process  or  the  maxillary  tuberosity;  h  The  second  molar 
sac  returned,  and  the  cavity  of  reserve  shortened ;  i  The  cavity  of  reserve  sending 
f'ff  the  sac  and  pulp  of  the  wisdom  tooth;  /The  sac  of  the  wisdom  tooth  advanced 
into  the  coronoid  process  or  maxillary  tuberosity  ;  k  The  sac  of  the  wisdom  tooth 
returned  to  the  extremity  of  the  dental  range. 


120  FORMATION   OF  THE  DENTINE, 

FORMATION   OP   THE   DENTINE. 

With  regard  to  the  manner  of  the  formation  of  the  den- 
tine, odontologists  do  not  agree.  Mr.  Thomas  Bell  is  of  the 
opinion  that  it  is  secreted  by  the  external  surface  of  the 
membrane  which  immediately  invests  the  pulp,  designated 
by  Raschkow,  the  ^^reformative  memhrane,  the  pulp  serving 
only  as  a  mould  upon  which  this  substance  is  formed. 
Purkiuje  and  Schwann  believe  that  the  pulp  is  converted 
into  dentine  by  a  transition  process,  the  superficial  cells 
upon  the  surface  assuming  first,  an  elongated  form,  corres- 
ponding in  diameter  and  direction  with  the  fibres  of  the 
dentine  ;  or,  in  other  words^  that  the  dentine  is  formed  by 
the  dentinification  of  the  pulp. 

Professor  Owen  maintains  that  it  is  by  ^^centripetal  calci- 
fication of  the  pulp's  substance."  He  says,  "in  the  cells  of 
the  dentinal  pulp  the  nucleus  fills  the  parent  cell  with  a 
progeny  of  nucleoli  before  the  work  of  calcification,"  more 
properly,  dentinification,  begins.  Again,  'Hhe  primary 
cells  and  the  capillary  vessels  and  nerves  are  imbedded  in, 
and  by  a  homogeneous,  minutely  subgranular,  mucilagi- 
nous substance.  The  cells  which  are  smallest  at  the  base 
of  the  pulp,  and  have  large,  simple,  subgranular  nuclei, 
soon  fall  into  linear  series,  directed  towards  the  periphery 
of  the  pulp :  where  the  cells  are  in  close  proximity  with 
that  periphery,  they  become  more  closely  aggregated,  in- 
crease in  size,  and  present  the  following  changes  in  their 
interior.  A  pellucid  point  a])pcars  in  the  centre  of  the  nu- 
cleus which  increases  in  size  and  becomes  more  opaque 
around  the  central  point,  rendering  the  compressorium 
requisite  for  its  demonstration.  A  division  of  the  nucleus 
in  the  course  of  its  long  axis  is  next  observed.  In  the  larger 
and  more  elongated  cells,  still  nearer  the  periphery  of  the 
pulp,  a  subdivision  of  the  nuclei  has  taken  place,  and  the 
subdivisions  become  elongated  Avith  their  long  axis  vertical 
or  nearly  so  to  the  plane  of  the  pulp,  and  to  the  field  of  cal- 


FORMATION   OF   THE   DENTINE.  121 

oification.     The   subdivided   and  elongated  nuclei  become 
attached  by  their  extremities  to  the  corresponding  nuclei  of 
the  cells  in  advance  ;  and  the  attached  extremities  become 
confluent.     Whilst  these  changes  are  proceeding,  the  calca- 
reous salts  of  the  surrounding  plasma  begin  to  be  accumu- 
lated in  the  interior  of  the  cells,  and  to  be  aggregated  in  a 
semi-transparent  state  around  the  central  granular  part  of 
the  elongated  nuclei,  which  now  present  the  character  of 
secondary  cells,  and  the  salts  occupy,  in  a  still  clearer  and 
more  comj)act  state,  the  interspaces  of  such  cells  ;  the  elon- 
gated granular  matter  of  the  terminally  confluent  secondary 
cells   establishes  the  area  of  the  tubes,  by  resisting,  as  it 
would  seem,  the  encroachment  of  the  calcareous  salts  ;  the 
nuclear  tracts  receiving  a  similar  proportion  of  the  salts,  in 
the  condition  of  minute  disintergrated  particles^  which  are 
usually  arranged  in  a  linear  series  of  nodules,  and  contrib- 
ute to  cause  the  white  color  of  the  moniliform  area  of  the 
tube,  when  viewed  by  reflected  light,  and  its  opacity  when 
viewed  by  transmitted  light.     Thus  the  primitive  existence 
of  the  granular  nuclei,  their  multiplication  in  the  primary  or 
parent  cell,  their  elongated  form,  their  serial  arrangement 
end  to  end,  and  terminal  confluence,  are  indicated  in  the 
calcified  pulp  by  the  area  of  the  dentinal  tubes  ;  the  inter- 
spaces of  the  metamorphosed  nuclei  being  occupied  by  cal- 
careous salts  in  a  clearer  and  more  compact  state,  with  evi- 
dence, however,  of  a  distinctness  of  the  nucleolar  membrane 
or  secondary  cell  from  the  cavity  of  the  common  containing 
cell,  which  sustains  the  interpretation  of  the  proper  parietes 
of  the  dentinal  tube.     The  indications  of  the  primitive  bouii. 
dary  or  proper  parietes  of  the  parent  cell  are  in  like  man- 
ner  more  or  less  distinctly  retained,  through  a  modification 
of  the  arrangement  of  the  calcareous  salts  in  the  boundaries 
and  in  the  interspaces  of  the  cells."     The  foregoing  is  but  a 
small  part  of  the  description  given  by  this  learned  writer, 
but  enough  to  show  his  views  upon  this  intricate  operation 
of  the  economy. 


122 


FORMATION    OF   THE   DENTINE. 


^'°-^^-  Mr.  Alexander  Nas- 

myth  says,  "the  cells 
of  the  pulp  are  con- 
verted into  ivory" 
(dentinal)  "cells  by 
the  deposition  with- 
in them  of  earthy 
salts,  and  the  cells 
so  converted,  with 
their  nuclei,  are  the 
perfect  ivory  ;  more- 
over, the  nuclei  as- 
sume a  peculiar  ar- 
rangement and  con- 
stitute the  structure 
which  I  have  des- 
cribed and  demon- 
strated by  the  name  of  baccated  fibres."  This  explana- 
tion of  the  manner  of  the  formation  of  dentine,  designated 
by  Mr.  Nasmyth  by  the  name  of  ivory,  differs  but  little 
from  that  given  by  Professor  Owen. 

The  changes  which  the  pulp  undergoes  a  little  before  and 
at  about  the  time  of  the  commencement  of  the  deposition  of 
earthy  salts  is  described  more  clearly  by  Mr.  Tomes  than  by 
any  preceding  writer.  He  divides  the  development  of  the 
pulp  into  three  stages.  The  first,  he  terms  the  areolar ; 
the  second,  the  cellular,  and  the  third,  the  linear  stage. 
The  first  embraces  the  period  of  the  earliest  appearance  of 
the  pulp  ;  the  second,  from  the  time  when  it  is  composed  of 
nucleated  cells  and  a  subgranular  uuitins  medium  to  the 


Fia.  47.  A  diagram  copied  from  Mr.  Nasmyth's  work  on  the  Development,  Struc- 
ture and  Diseases  of  the  Teeth,  showing  the  vascular  and  cellular  structure  of  the 
pulp  of  a  tooth,  and  the  conversion  of  the  cells  into  dentine,  a  "The  blood-ves- 
sels and  capillaries  of  the  pulp,  between  which  the  cellular  structure  is  seen." 
h  "The  cells  in  process  of  conversion  into  ivory,"  or  rather  dentine,  "and  occu- 
pying the  peripheral  portion  of  the  pulp."  "In  the  line  between  c  c,  the  transi- 
tion of  these  cells  into  the  structure  of  ivory,"  or  dentine,  is  more  clearly  exhib- 
ited. 


FORMATION   OF   THE   DENTINE. 


123 


period  when  the  former  begins  to  assume  a  linear  arrange- 
ment, which  arrangement,  immediately  precedes  dentinifi- 


cation,    and    consti- 


Fio.  48. 


tutes  the  third  stage. 
The  cells  nearest  to 
the  coronal  surfaces 
are  the  first  to  as- 
sume this  position. 
The  columns  thus 
formed  of  the  cells 
take  an  arrangement 
nearly  vertical  to 
the  coronal  surface^  or  corresponding  to  the  direction  of  the 
dentinal  tubes  or  fibres  of  the  perfected  tooth,  and  running 
parallel  to  each  other.  Scarcely  any  trace  of  the  areolar 
tissue  seen  in  the  first  or  earlier  stage  can  be  detected  in 
this  or  the  second  stage. 

These  three  conditions,  in  the  advanced  pulp,  are  not  dis- 
tinguished according  to  Mr.  Tomes^  by  well  defined  lines  of 
demarcation,  ''but  are  beautifully  blended,  the  one  with  the 
other,  passing  from  the  one  extreme  of  condition  to  the  other 
so  gradually  that  the  transitions  are  not  at  first  recognized, 
and  when  fully  recognized  are  again  lost  in  the  gradations 
towards  a  further  change." 

The  cells  decrease  in  size  from  the  surface  toward  the  cen- 
tral portion  of  the  pulp,  but  the  smaller  increases  to  the 
size  of  the  larger  when  the  time  for  their  dentinification 
arrives.  Each  cell  after  falling  into  line,  divides  into  two 
or  more  in  its  length,  and  each  division  elongates.  A  cen- 
tral nucleus  or  open  space  is  seen  in  each  cell,  which  length- 
ens with  the  cell.  The  cells  by  their  increased  length  be- 
come placed  end  to  end,  and  ultimately  unite  ;  and  the 
elongated  central  space  of  each  individual,  by  a  further  de- 

FiG.  48.  The  pulp  in  its  second  stage  composed  of  nucleated  cells  and  subgranu- 
lar  plasma. 

Fig.  49.  The  pulp  in  the  early  part  of  the  third  stage,  showing  the  cells  arranged 
in  lines.     Copied  from  Mr.  Tomes. 


124 


FORMATION    OF    THE   DENTINE. 


velopment,  joins  and  opens  into  tliose  of  tlie  super-imposed 
cells  ;  thus  forming  a  central  tube  common  to  tbe  linearly 
imited  cells/'  as  seen  in  Fig.  50.     ''At  or  a  little  before  this 
Fig.  50.  period  of  development  the  earthy 

matter  is  received  into  the  cellular 
or  rather  tubular  and  intertubu- 
lar  tissue,  whereby  the  gelatinous 
matrix_,  having  assumed  the  re- 
quired form,  is  converted  into 
tubular  and  intertubular  tissue  ; 
in  other  words  into  dentine.  In 
some  instances  the  linearly  ar- 
ranged cells  have  two  or  even  three  central  cavities,  but  in 
the  progress  of  development  they  become  joined  in  one. 
Sometimes  they  appear  empty,  at  other  times  occupied  by 
granular  matter.  In  either  case  they  are  usually  described 
under  the  name  of  nuclei."  The  transparent  structureless 
membrane  enclosing  the  pulp  is  the  first  to  undergo  solidi- 
fication. 

Professor  Kolliker  entertains  very  nearly  the  same  oi^in- 
ion  with  regard  to  the  manner  of  the  formation  of  dentine 
as  that  expressed  by  Mr.  Tomes.  After  advancing  three 
hypotheses,  he  concludes  by  expressing  the  belief,  that  the 
matrix  of  the  dentinal  tubes,  the  intertubular  tissue,  "pro- 
ceeds from  the  cylindrical  cells  investing  the  pulp  of  the 
tooth,  which  undergo  a  greater  or  less  elongation,  coalesce 
and  ossify."  The  canaliculi,  or  tubes,  he  believes,  arise, 
either  from  the  nuclei  of  these  cells,  or  are,  which  he  be- 
lieves to  be  more  probable,  the  remains  of  the  cavities  of  the 
cells,  the  boundaries  of  which  having  undergone  greater 
consolidation,  and,  therefore,  correspond  with  lacunse  of 
bone.  The  divisions,  he  thinks,  may  be  owing  to  a  longi- 
tudinal division,  from  time  to  time,  of  the  cells,  or  by  the 
union  of  one  cell  with  two. 


Fig.  60.  The  pulp  in  the  third  stage,  showing  the  cells  placed  end  to  end  and 
becoming  confluent ;  also,  two  lines  of  cells  uniting  to  form  one. 


FORMATION   OF   THE  ENAMEL.  125 

The  foregoing  brief  summary  of  the  opinions  of  the 
authors  referred  to,  will  serve  to  convey  a  tolerably  correct 
idea  of  the  views  at  present  entertained  with  regard  to  the 
manner  of  the  formation  of  dentine. 

FORMATION  OP  THE  ENAMEL  OP  THE  TEETH. 

The  opinion  formerly  entertained  upon  this  subject  was, 
that  the  enamel  is  a  deposition  from  the  inner  membrane  of 
the  dental  sac;  that  this,  after  the  surface  of  the  pulp  of  the 
tooth  has  dentinified,  pours  out  upon  it  a  thick  fluid,  which 
soon  condenses,  assuming  at  first  a  chalky  appearance,  and, 
afterAvards,  by  a  process  somewhat  similar  to  crystallization, 
attains  the  glossy-like  hardness  by  which  it  is  characterized. 
The  author  was  for  a  long  time  of  this  opinion,  but  recent 
observations,  strengthened  by  a  perusal  of  the  thesis  of 
Raschkow,  have  led  him  to  believe  it  erroneous. 

The  gelatinous  granular  substance  mentioned  by  Groodsir, 
and  called  by  Raschkow  the  adamantine  organ,  situated 
between  the  follicle  and  tooth  germ — the  latter  of  which  it 
invests^  at  first  loosely,  but  afterwards  more  closely,  mould- 
ing itself  to  the  pulp,  there  is  good  reason  to  believe,  is  des- 
tined for  the  formation  of  the  enamel.  It  is  represented  by 
the  last  named  author  as  forming  a  globular  nucleus 
between  the  follicle  and  dental  germ  at  a  very  early  period 
of  the  growth  of  the  latter_,  with  a  bulging  externally,  and 
presenting  a  parenchymatous  appearance  internally ;  but 
gradually  exhibiting  angular  granulations,  held  together 
by  filaments  of  cellular  tissue,  resembling  "a  kind  of  acti- 
nenchyma,  such  as  may  be  seen  in  plants."  It  was  the 
discovery  of  this  granular  substance  in  dissecting  the  jaws 
of  a  pig  that  first  induced  the  writer  to  suppose  the  old 
doctrine  of  the  formation  of  the  enamel  to  be  incorrect.  It 
is  at  first  as  represented  by  Raschkow  and  Goodsir,  discon- 
nected from  the  dental  germ,  surrounded  by  fluid,  bearing 
a  striking  resemblance  to  the  liquor  amnii,  but  is  gradually 
transformed  into  a  membrane,  and  as  dentinification  com- 


126  FORMATION   OF   THE   ENAMEL. 

mences  in  the  pulp,  attaches  itself  to  it,  and  adheres  with 
considerable  tenacity. 

It  was  no  doubt  the  discovery  of  this  that  led  Delabarre 
to  suppose  the  enamel  an  integral  part  of  the  tooth  and  pro- 
ceeding from  the  dental  embryo,  for  he  speaks  of  the  forma- 
tion of  this  outer  coating  of  the  teeth  as  being  produced  by 
an  immense  number  of  small  exhalent  vessels  which  formed 
a  sort  of  imperceptible  velvet.  Into  these  he  believed  the 
phosi)hate  of  lime  was  deposited,  and  in  such  a  way  as  not 
to  destroy  their  organic  sensibility. 

Easchkow  says,  "The  dental  germ,  in  advancing  further 
and  further  into  the  dental  follicle,  makes  first  only  a  slight 
impression  on  the  globular  mass  of  the  enamel  organ^  but 
this  impress  is  rendered  gradually  deeper  as  the  growth  of 
the  germ  jDroceeds.  When  the  germ  has  penetrated  further 
into  the  hollow  thus  made,  it  appears  narrower  towards  the 
base,  and  thicker  under  the  apex,  and  is  enclosed  around  on 
every  side  by  the  parenchyma  of  the  enamel-organ,  which 
thus  assumes  the  appearance  of  a  hood,  covering  the  dental 
germ  when  advanced  in  its  develojiment,  and  capable  of 
being  separated  from  it  without  difiiculty,  and  without 
injury,  either  by  the  compressor,  or  in  any  other  manner, 
by  being  placed  under  water."  He  also  represents  it  as 
being  disconnected  from  the  dental  capsule,  except  at  the 
coronal  portion,  where  it  seemed  to  be  united  by  some  loose 
vessels ;  it  is  thus  that  he  accounts  for  the  numerous 
capillaries  which  pervade  the  parenchyma  of  the  organ; 
and  from  this,  he  assumes  that  wliile  the  dental  germ  has 
its  origin  from  the  extremity  of  the  sac  next  the  root,  the 
enamel-organ  originates  from  the  opposite  or  coronal  ex- 
tremity, and  that  arising  at  opposite  points,  they  ''approach 
each  other,  are  adapted  together_,  and  both  contribute  to  the 
production  of  the  tooth." 

After  the  enamel-organ  has  adapted  itself  to  the  dental 
pul]),  a  peculiar  organ  is  seen  on  its  inner  surface,  consist- 
ing of  short  uniform  fibres  placed  perj)endicularly  "to  the 
cavity,  and   forming,    as  it   were^    a   silky  lining"    to   it, 


FORMATION   OF   THE  ENAMEL.  12 "7 

whicli,  in  a  transverse  section  of  tlie  enamel-organ_,  may  be 
'^clearly  seen,  and  can  be  accurately  distiuguisbed  from  the 
otber  stellated  parenchyma  of  the  substance"  which  Rasch- 
kow  designates  the  enamel  pulp. 

According  to  this  author,  this  stratum  of  fibres,  originat- 
ing in  "the  transformation  of  the  pulp  of  the  enamel,"  with 
which  it  is  for  a  time  connected,  afterwards  separates  from 
it,  so  as  only  to  adhere  by  "a  few  filaments  of  cellular 
tissue;  and  beconles  a  genuine  membrane;"  this,  on 
account  of  the  function  it  performs,  he  styles  the  enamel 
membrane.  "Its  inner  surface  consists  of  hexangular, 
nearly  uniform,  corpuscles,  visible  only  through  a  magnify- 
ing glass ;  towards  the  centre  of  each  of  which  is  a  round 
eminence.  These  corpuscles  are  nothing  more  than  the 
ends  of  short  fibres,  of  which  the  whole  membrane  is  com- 
posed ;  and  which  being  pressed  together,  assume  freely  the 
hexangular  form."  These  he  describes  as  being  disposed 
in  regular  series^  and  corresponding  with  the  arrangement 
of  the  enamel  fibres. 

Each  of  these  fibres  is  an  excretory  duct  or  gland,  whose 
peculiar  function  it  is  to  secrete  the  "enamel  fibre  corres- 
ponding to  it."  Immediately  after  the  commencement  of 
dentinification  of  the  pulp,  each  one  of  these  fibres,  with  its 
inner  extremity  placed  upon  the  now  forming  subjacent 
dentine,  begins  to  secrete  the  earthy  salts  of  which  this  sub- 
stance is  chiefiy  composed.  While  this  is  going  on,  an  or- 
ganic lymph  seems  to  be  secreted  from  the  parenchyma  of 
the  enamel-membrane  which  penetrates  between  the  indi- 
vidual fibres,  and  renders  their  whole  substance  soft.  This, 
by  means  of  a  "chemico-organic  process,"  afterwards  com- 
bines with  the  earthy  substances,  and  forms  the  animal  base 
of  the  enamel. 

It  has  been  shown  by  Raschkow,  that  the  dental  pulp  is 
invested  by  a  very  delicate  membrnne,  which  he  denomi- 
nates the  preformative  membrane,  and  there  is  every  reason 
to  believe,  that  this  constitutes  the  bond  of  union  between 
the  enamel  fibres  and  the  dentine  of  the  tooth. 


128  FORMATION   OF   THE   CRUSTA   PETROSA. 

Admitting  this  theory  of  the  formation  of  the  enamel  to 
be  correct,  the  frame  work  of  animal  tissue,  spoken  of  by 
Mr,  Nasmyth,  as  entering  into  the  composition  of  this  sub- 
stance,, is  readily  accounted  for.  In  no  other  way,  except 
the  theory  of  Delabarre  be  correct,  and  this  is  by  far  the 
most  plausible,  can  its  presence  be  satisfactorily  explained. 

With  regard  to  the  manner  of  the  formation  of  Nasmyth' s 
memhirme,  Professor  Kulliker  inclines  to  the  opinion  that  it 
is  '^a  calcified,  amorphous  exudation,  secreted  from  the  en- 
amel organ  immediately  after  the  ossification  of  the  last  en- 
amel cells^  which  glues  together  and  protects  the  ends  of  the 
prisms  of  the  enamel."  Huxley,  on  the  other  hand,  believ- 
ing the  enamel  to  be  formed  beneath  the  membrane  which 
invests  the  pulp,  called  by  Easchkow  the  preformative  mem- 
brane, is  of  opinion  that  Nasmyth's  membrane  is  merely  an 
altered  condition  of  this.  His  theory,  however^  of  the  man- 
ner of  the  formation  of  the  enamel  prisms,  as  well  as  of  the 
membrane  in  question,  lacks  conformation.  That  part 
which  relates  to  the  formation  of  the  enamel  fibres,  is  little 
more  than  a  revival  of  the  theory  of  Delabarre. 

FORMATION   OP   THE   CEMENTUM,   OR  CRUSTA   PETROSA. 

The  manner  of  the  formation  of  the  cementum,  has  been 
variously  explained.  Easchkow  conjectures  that  it  is  prob- 
ably produced  by  the  remains  of  the  enamel  pulp.  More 
recent  writers  seem  to  regard  the  cemental  pulp  as  a  pro- 
duction of  the  dental  sac,  but  the  writer  is  inclined  to  believe 
that  it  is  a  production  of  that  portion  of  the  preformative 
membrane  which  invests  the  elongated  part  of  the  pulp 
destined  for  the  formation  of  the  root,  and  that  this,  as 
earthy  salts  are  deposited  in  the  pulp,  pours  out  a  blastema 
in  Avhich  nucleated  cells  are  developed.  He  was  led  to  the 
adoption  of  this  belief  from  an  examination  of  a  tooth,  on 
every  part  of  the  surface  of  which,  there  is  a  development  of 
exostosis.  Such  development  is  now  universally  admitted 
to  be  a  hypertrophied  condition  of  cementum,  the  structure 
of  the  former  being  identical  with  the  latter. 


FORMATION   OF   THE  CRUSTA   PETROSA,  129 

The  tootli  in  question  belongs  to  the  Museum  of  the  Bal- 
timore Dental  College,*  and  the  development  of  the  exos- 
tosis must  have  commenced  simultaneously  with  the  com- 
mencement of  the  deposition  of  earthy  salts  in  the  dentinal 
pulp,  and  so  rapidly  did  it  proceed,  that  it  completely  broke 
up  the  enamel  organ,  penetrating  every  part  of  it,  so  that 
only  here  and  there,  imbedded  in  its  substance,  small 
patches  of  enamel  are  seen.  This  phenomenon  can  only  be 
accounted  for  by  supposing  that  the  investing  membrane  of 
the  pulp,  from  some  inexplicable  cause,  poured  out  a 
blastema,  which  was  immediately  converted  into  cementum, 
and  that  this  took  on  a  hypertrophied  condition  before,  or 
Bimultaneously  with^  the  deposition  of  earthy  salts  in  the 
cells  of  the  fibres  of  the  enamel  organ. 

*  It  was  presented  to  the  Author,  for  this  icstitution,  hj  Dr.  Swa^yze, 


CHAPTER    EIGHTH. 

FIRST    DENTITION. 

The  crowns  of  tlie  temporary  teetli,  as  has  been  shown, 
are  solidified  and  coated  with  enamel  at  birth,  and  although 
at  about  this  period  the  roots  of  the  incisors  begin  to  be 
formed,  yet  they  still  occupy  their  bony  cells  in  the  alveolar 
ridge.  But,  as  the  time  approaches  when  the  system  re- 
quires a  diet  better  suited  to  the  support  of  its  increasing 
energies  than  milk,  the  one  on  which  the  child  has  hitherto 
subsisted,  nature,  as  if  conscious  of  the  change  about  to  take 
place,  calls  into  action  certain  agents,  by  which  the  ojDen- 
ings  in  the  alveolar  cells  are  enlarged,  and  through  which, 
in  obedience  to  an  established  law,  tlie  little  gems,  sparkling 
with  whiteness,  gradually  and  slowly  emerge,  pair  after 
pair,  until  the  pearly  arches  are  completed,  to  answer  the 
demands  of  increasing  wants,  and  to  assist  in  the  articula- 
tion of  those  lisping  accents,  by  which  the  child's  early 
wishes  are  made  known. 

Dentition  is  divided  by  Mr,  Goodsir.  into  three  stages, 
namely,  the  Follicular,  the  Sacular,  and  the  Eruptive. 
The  two  first  have  already  been  considered,  and  it  now  only 
remains  to  treat  of  the  last. 

ERUPTION   OF   THE   TEMPORARY   TEETH. 

Various  opinions  have  been  advanced  with  regard  to  the 
manner  in  which  the  passage  of  a  tooth,  from  the  alveolus 
through  the  gum,  is  effected.  fSome  suppose  it  is  the  result 
of  the  elongation  of  the  pulp  for  the  formation  of  the  root ; 
others,  that  it  is  a  consequence  of  the  moulding  of  the  alve- 


ERUPTION    OF   THE   TEMPORARY  TEETH,  131 

oliis  around  the  latter,  as  it  is  formed.  Some  believe  tliat 
the  opening  through  the  gum  is  etFected  by  the  mechanical 
action  of  the  coronal  extremity  of  the  advancing  tooth  ; 
others,  and  with  far  more  plausibility  of  reason,  that  it  is 
the  result  of  the  action  of  absorbent  vessels. 

The  able  physiologist  and  learned  dentist,  Delabarre,  has 
advanced  a  most  ingenious  theory  upon  this  subject.  He 
believes  that  the  passage  of  a  tooth  through  the  gum,  or 
rather  its  escape  from  its  matrix,  is  effected  in  precisely  the 
same  manner  as  is  the  birth  of  a  child.  He  regards  the  sac, 
the  gums  forming  one  point  of  attachment  for  it,  and  the 
neck  of  the  tooth  the  other,  as  the  chief  agent,  and  believes 
that  it  is  by  the  contraction  of  this,  that  the  latter  is  raised 
from  the  bottom  of  the  alveolus,  and  ultimately  forced 
through  the  dilated  orifice  of  the  former  and  gums. 

This  is  the  most  rational  theory  that  has  been  advanced ; 
it  explains,  upon  princ!i3les  of  sound  physiology,  this  most 
wonderful  and  curious  operation  of  the  economy.  It  is  dif- 
ficult to  imagine  how  the  elongation  of  the  pulp,  or  the 
moulding  of  the  alveolar  walls  to  it,  can  have  any  agency  in 
forcing  the  tooth  through  the  gums.  If  the  elongation  of 
the  pulp  commenced  before  the  crown  of  the  tooth  had  made 
any  advance  towards  the  gums,  it  would  at  once  come  in 
contact  with  the  floor  of  the  alveolus,  and  in  its  soft  and 
yielding  condition,  be  caused  to  assume  a  configuration  dif- 
ferent from  that  presented  by  the  root  of  a  naturally  devel- 
oped tooth.  The  crown  of  the  tooth,  therefore,  must  make 
some  progress  towards  the  gum_,  before  the  elongation  of  its 
pulp  can  commence^  and  it  is  difiicult  to  conceive  how  this 
can  be  effected,  if  it  is  not  by  the  contraction  of  the  sac. 

This  theory  is  objected  to  by  some,  on  the  ground  that 
the  two  membranes  of  which  the  dental  matrix  or  sac  is 
composed,  are  of  a  fibrous  structure,  and  consequently,  not 
endowed  with  contractile  properties  ;  but  the  microscope  of 
Mr,  Nasmyth,  has  shown  that  the  inner  lamina  is  composed 
of  layers  of  cells,  loosely  arranged,  and  separated  by  inter- 
spaces equal  to  half  the   diameter  of  the  cell.     In  another 


132  ERUPTION   OF   THE  TEMPORARY  TEETH. 

place,  the  same  writer  observes,  that  the  inner  lamina  seems 
to  partake  more  of  the  nature  of  a  serous  than  of  a  mucous 
membrane.  That  the  sac  does  contract,  is  proven  by  the 
fact,  that  it  shortens  as  the  tooth  advances,  so  that,  ulti- 
mately, after  the  complete  extrusion  of  the  crown,  it  consti- 
tutes the  free  edge  of  the  gum. 

The  dentinification  of  the  exterior  of  the  root  of  the  tooth 
proceeds  nearly  as  fast  as  the  elongation  of  the  pulp  for  its 
formation.  Commencing  at  the  neck,  it  proceeds  inwards 
and  downwards,  forming  concentric  layers,  one  within  and 
above  the  other,  until  it  reaches  the  extremity,  and  nothing 
remains  but  a  small  canal  running  through  the  centre,  from 
its  apex  to  the  cavity  in  the  crown,  through  which  the  den- 
tal vessels  and  nerves  pass.  The  alveolus,  in  the  meantime, 
deepens  ;  its  walls  approach  each  other,  and  closely  embrace 
the  root  of  the  tooth. 

As  soon  as  the  edge  of  the  coronal  extremity  of  the  tooth 
comes  through  the  gum,  the  sac  assumes  its  primitive  fol- 
licular condition,  but  still  connected  with  the  neck  of  the 
tooth,  it  continues  to  contract  until  the  whole  of  the  crown 
has  emerged  from  the  gum. 

The  periods  of  the  eruption  of  the  temporary  teeth  is  va- 
riable, depending  probably  upon  the  state  of  the  constitu- 
tional health.  The  following,  however,  may  be  regarded 
as  a  very  near  approximation,  namely  : 

The  central  incisors  from  5  to    8  months  after  birth. 

"   lateral  incisors     ''     7  to  10         "         "         " 

"   first  molars  "  12  to  16         ''         ''         " 

-.   ''   cuspidati  "  14  to  20         ''         "         " 

''   second  molars       ''  20  to  36         "         "         " 

No  general  rule,  however,  can  be  laid  down  from  which 
there  will  not  be  frequent  variations.  The  following  is  the 
most  remarkable  case  of  deviation,  not  only  from  the  most 
usual  period,  but  also  from  the  natural  order  of  the  eruption 
of  the  teeth  which  the  author  has  ever  met  with.  In  No- 
vember, 1846,  he  was  sent  for  to  lance  the  gums  of  an  in- 
fant only  four  months  old.     On  examining  the  mouth,  the 


ERUPTION   OF   THE   TEMPORARY   TEETH.  133 

gums  on  each,  side,  both  in  the  lower  and  upper  jaws,  about 
where  the  first  temporary  molars  are  situated,  were  found 
much  swollen  and  inflamed.  As  these  teeth  were  evidently 
forcing  their  way  through  the  gums,  and  as  the  child  was 
threatened  with  convulsions,  it  became  necessary  to  lance 
them  immediately.  This  was  accordingly  done,  which  gave 
instant  relief  to  the  little  sufferer.  In  a  few  days  after,  the 
teeth  made  their  appearance,  but  the  eruption  of  the  cen- 
tral incisors  did  not  take  place  until  about  the  seventh 
month. 

There  is  sometimes  an  extraordinary  tardiness  of  action 
in  the  eruption  of  the  temporary  teeth.  There  is  a  case 
of  a  child,  somewhere  on  record,  that  did  not  get  any  of  its 
teeth  until  it  was  ten  years  old.  Lefoulon  states  that  he 
saw  a  young  girl  of  seven  years  of  age,  whose  inferior  inci- 
sors had  not  appeared.  Several  cases  have  come  under  the 
observation  of  the  author  in  which  dentition  did  not  com- 
mence until  the  fifteenth,  and  one  not  until  the  twentieth 
month.  On  the  other  hand,  there  are  cases  of  precocity  of 
action  in  the  eruption  of  the  teeth  equally  remarkable,  as 
for  example,  when  the  two  lower  incisors  are  erupted  at 
birth  ;  such  occurrences  have  been  met  with.  Louis  XIV 
was  born  with  four  teeth,  and  Polydorus  Virgilius  mentions 
a  child  that  was  born  with  six.  Haller,  in  his  Elements  of 
Physiology,  enumerates  the  cases  of  nineteen  children  who 
were  born  with  teeth.  Other  examples  are  on  record,  and 
there  are  few  physicians  or  dentists  who  have  been  in  prac- 
tice ten  or  fifteen  years,  who  have  not  met  with  like  cases. 

In  speaking  of  those  early  productions,  Mr.  Fox  says, 
"As  they  only  have  a  weak  attachment  to  the  gums,  they 
soon  get  loose,  producing  a  considerable  inflammation  in 
the  mouth  of  the  child,  as  well  as  occasioning  considerable 
inconvenience  to  the  mother.  It  is,  therefore,  advisable  to 
extract  them  immediately,  for  they  can  never  come  to  per- 
fection." The  author  is  compelled  to  differ  with  Mr.  Fox, 
for  their  attachment  is  not  always,  as  he  supposes,  confined 
to  the  gums  ;  their  roots  are  sometimes  securely  fixed   in 


134  ERUPTION    OF   THE    TEMPORARY   TEETH. 

sockets  in  the  jaw.  When  this  is  the  case,  they  seldom 
occasion  much  inconvenience,  and  their  extraction  would  be 
highly  improper.  It  is  always  better,  therefore,  to  wait 
until  there  is  some  positive  indication  that  such  operation  is 
necessary,  before  performing  it. 

In  the  eruption  of  the  teeth,  nearly  the  same  order  is  fol- 
lowed that  is  observed  in  their  solidification.  The  central 
incisors  appear  first,  then  the  lateral,  next  the  first  molars, 
afterwards  the  cuspidati,  and,  lastly,  the  second  and  third 
molars. 

The  lower  teeth  in  their  eruption,  are  said,  usually^  to 
precede  the  uj)per  about  two  or  three  months,  but  the  upper 
appear  first  nearly  as  often  as  the  lower. 

MORBID   EFFECTS   RESULTING  FROM   FIRST    DENTITION. 

When  we  consider  the  early  age  at  which  first  dentition 
commences,  and  the  fragile  and  irritable  state  of  the  system, 
it  will  not  appear  wonderful  that  infants  should  so  frequent- 
ly suffer  from  the  efforts  of  the  economy  for  the  liberation  of 
these  organs  from  the  bony  cells  and  superincumbent  gums, 
in  which  tliey  are  confined.  The  constitution,  at  this  ten- 
der period  of  life,  often  receives  a  shock  from  which  it  never 
recovers  ;  and  the  seeds  of  many  chronic  diseases  are  caused 
to  germinate,  which,  otherwise,  in  all  probability,  would 
have  forever  remained  dormant. 

This  is  generally  regarded  as  the  most  critical  period  of 
life,  and  it  has  often  proved  one  of  bereavement  and  sorrow. 
The  whole  process  is  sometimes  completed  without  inconve- 
nience, but,  at  other  times,  it  is  attended  with  so  much  pain 
and  irritation  that  the  most  alarming  and  complicated  forms 
of  disease  result  from  it. 

The  irritation  accompanying  first  dentition  is  supposed  to 
be  caused  by  the  pressure  which  the  teeth  make  upon  the 
gums  in  forcing  their  way  out,  which  irritation  varies  in  ex- 
tent, according  to  the  healtli  and  teraijerament  of  the  child. 
When  the  absorption  of  the  gums  and  dilatation  of  the  neck 


EFFECTS   OF   FIRST  DENTITION.  135 

of  the  sac  keep  pace  witli  the  growth  of  the  tooth,  the  i3re8- 
sure  is  scarcely  perceptible  ;  but  when  these  functions  are 
tardily  iierformed  it  becomes  more  or  less  great,  in  propor- 
tion as  the  growth  of  the  one  outstrips  the  absorption  and 
dilatation  of  the  other.  It  may  be,  that  much  of  the  irrita- 
tion is  produced  by  the  pressure  of  the  tooth  upon  the  pulj), 
for,  when  its  progress  is  retarded  by  the  resistance  of  the 
gums,  the  elongation  of  this,  for  the  formation  of  the  root^ 
would,  of  necessity,  cause  the  solidified  part  to  press  upon  it, 
which,  as  a  matter  of  course,  would  give  rise  to  great  pain 
and  irritation. 

Dr.  Good  is  of  opinion  that  the  pressure  of  the  teeth 
against  the  gums  "is  not  uniformly  exerted  through  the 
course  of  teething,  but  is  divided  into  distinct  periods  or 
stages  as  though  the  vital  or  instinctive  principle,  which  is 
what  we  mean  by  nature,  becomes  exhausted  by  a  certain 
extent  of  action,  and  requires  rest  and  a  state  of  intermis- 
sion. 

"The  first  or  active  stage  of  teething  is  usually  about  the 
third  or  fourth  month  of  infancy,  and  constitutes  what  is 
called  breeding  the  teeth,  or  the  conversion  of  the  pulpy 
rudiment  buried  in  the  gums,  and  formed  during  fetal  life, 
into  a  solid  material,  which,  at  the  same  time,  shoots  down- 
ward, and  gives  to  every  tooth  a  neck  or  fang." 

The  j)eriod  of  dentition  here  referred  to  is  the  time  when 
the  sac  begins  to  contract.  The  coronal  extremity  of  the 
tooth  is  then  brought  in  contact  with  the  sac,  and  when  the 
formation  of  the  root  of  the  former  proceeds  more  rapidly 
than  the  contraction  of  the  latter,  the  root  comes  in  contact 
with  the  bottom  of  the  alveolus,  and  doubtless  much  of  the 
irritation,  as  we  have  before  intimated,  resulting  from  den- 
tition, is  attributable  to  this  circumstance.  But  Dr.  G.  is 
mistaken  in  supposing  that  the  pulpy  rudiment  begins  to  be 
converted  into  a  solid  material,  at  the  third  or  fourth  month 
of  infancy,  when,  what  he  terms  the  first  or  active  stage  of 
teething  commences.  Several  layers  of  dentine  are  perfectly 
formed  over  most  of  the  pulps  of  the  temporary  teeth  at 


136  EFFECTS  OF  FIRST  DENTITION. 

birth,  tliougli  the  enamel  is  not  quite  completed  at  so  early 
a  period.  The  doctor  has  evidently  confounded  the  com- 
mencement of  the  elongation  of  the  pulp  with  that  of  its 
solidification. 

During  the  period  of  teething,  the  child  is  restless  and 
fretful,  but  its  paroxysms  of  suffering  are  periodical,  and 
seldom  last  more  than  two  or  three  hours  at  a  time  ;  where- 
as, were  the  pressure  of  the  teeth  upon  the  gums  uniform 
and  constant,  there  would  be  no  intermissions.  The  repose 
thus  afforded,  enables  the  system  to  recover  in  some  degree 
from  the  exhaustion  occasioned  by  each  preceding  jmroxysm. 
If  it  were  not  for  this,  its  excited  energies  would  soon  be 
worn  out,  and  the  child  fall  a  victim  to  the  continued  in- 
tensity of  its  sufferings. 

When  the  irritation  is  merely  local,  it  is  usually  of  short 
duration,  and  consists  in  a  slight  tenderness  and  tumefac- 
tion of  the  gums,  accompanied  by  increased  secretion  of 
saliva.  But  when  it  is  sufficiently  great  to  effect  the  func- 
tional operations  of  other  parts  of  the  system,  febrile  symp- 
toms of  a  general  and  more  or  less  aggravated  character, 
supervene,  attended  with  drowsiness,  diarrhea^  and  not  un- 
frequently,  with  various  cutaneous  eruptions,  as  the  red 
gum,  and  of  pustules,  at  first  filled  with  limpid  fluid,  but 
which,  afterwards,  become  purulent.  The  former  appear 
on  the  neck  and  face  :  the  latter  are  not  confined  to  any 
particular  part  of  the  body,  but  are  either  thinly  scattered 
over  its  whole  surface,  or  appear  in  small  patches.  There 
is  also  another  kind  of  eruption  which  breaks  out  about  the 
mouth,  cheeks  and  forehead,  sometimes  extending  to  the 
scalp,  which,  in  a  short  time  dries  up  and  becomes  covered 
with  disagreeable  scabs.  These  drop  ofi",  after  a  while,  to  be 
succeeded  by  others. 

These  eruptions  are  generally  regarded,  as  indications  of 
the  substitution  of  a  milder  for  a  more  aggravated  form  of 
disease,  and  should  not,  therefore,  be  too  hastily  suppressed. 

To  these  symptoms,  we  may  add,  cough,  spasms  of  the 
muscles  of  the  face^  particularly  of  those  about  the  mouth. 


EFFECTS   OF   FIRST  DENTITION.  137 

and,  when  the  diarrhea  is  so  copious  as  to  occasion  great 
emaciation,  convulsions  and  death,  sometimes,  supervene. 

Thus  far,  we  have  merely  glanced  at  a  few  of  the  eiFects 
of  first  dentition.  To  attempt  a  description  of  all,  would  in- 
volve the  enumeration  of  the  whole  catalogue  of  diseases  pe- 
culiar to  infancy,  and  which,  as  they  more  properly  helong 
to  another  branch  of  medicine,  we  shall  neither  stop  to  de- 
scribe nor  point  out,  minutely,  their  curative  indications. 

It  may  be  well,  however,  to  state,  that  the  local  treat- 
ment consists  in  making  a  free  incision  with  a  lancet  through 
the  tumefied  gum,  down  to  the  advancing  tooth.  This,  in 
very  many  cases,  affords  immediate  relief  and  supersedes  the 
necessity  of  other  treatment.  It  is  objected  to  by  some,  on 
the  ground,  that,  though  it  may  afi'ord  temporary  relief,  the 
cicatrix  formed  by  the  healing  of  the  wound,  constitutes  a 
greater  obstacle  to  the  exit  of  the  tooth,  than  the  parts  ever 
do  when  left  to  themselves.  Now,  any  one  at  all  convers- 
ant with  the  subject^  knows  that  in  four  cases  out  of  five, 
where  the  operation  is  necessary,  the  teeth  are  so  far  ad- 
vanced, that  Avhen  the  incised  gums  collajjse,  their  crowns 
immediately  protrude  :  and  even  when  the  wound  does  unite^ 
the  soft  and  spongy  cicatrix  yields  more  readily  to  the  action 
of  the  absorbents  than  the  gums  do  in  their  natural  state. 

Another  objection  is  founded  upon  the  supposition  that 
the  enamel,  at  this  early  period,  is  in  a  soft  and  amor- 
phous state,  and  that,  consequently,  the  teeth  may  be  in- 
jured by  the  contact  of  the  knife.  But  as  the  parts  of  the 
enamel  exposed  to  the  instrument  usually  attain  their  great- 
est hardness  before  such  operation  is  required,  this  objection 
is  without  foundation.  In  short,  we  have  never  known  any 
injury  to  result  from  it,  either  in  our  own  practice,  or  in 
that  of  others :  nor  can  those  who  are  opposed  to  it,  bring 
facts  to  support  their  opposition. 

It  is  true_,  there  is  sometimes  considerable  hemorrhage, 
which,  in  two  or  three  instances,  has  terminated  fatally, 
but  it  rarely  happens  that  this  is  very  considerable,  and  it 
almost  always  subsides  in  a  few  minutes. 
10 


138  EFFECTS   OF   FIRST  DENTITION. 

This  simple  operation  often  succeeds  after  all  others  have 
failed.  We  have  frequently  known  children,  after  having 
suftered  the  greatest  agony  for  days  and  weeks,  and  until 
they  had  become  reduced  to  mere  skeletons,  obtain  imme- 
diate relief  without  any  other  treatment.  This  at  once  re- 
moves the  cause,  whereas^  other  remedies  only  counteract 
the  effects  of  the  suffering,  and  can  only  be  considered  as 
palliatives  that  may  assist  nature  in  her  struggles  with  dis- 
ease, but  cannot  always  prevent  her  from  sinking  in  the 
contest. 


CHAPTER    NINTH. 

SHEDDING  OF   THE   TEMPORARY  TEETH. 

Some  very  singular  notions  were  entertained  among  tlie 
ancients  concerning  tlie  temporary  teeth.  Many  thought 
they  never  had  roots,  inasmuch  as  they  were  observed  to  be 
wanting  when  they  dropped  out ;  others,  that  the  crowns 
were  removed,  while  the  roots  remained  and  afterwards 
grew  and  became  the  permanent  teeth. 

This  most  wonderful  operation  of  the  economy  is  affected 
in  accordance  with  an  established  law,  but  there  exists, 
among  physiologists,  some  difference  of  opinion  with  re- 
gard to  the  precise  manner  in  which  it  is  effected.  Most 
writers  ascribe  their  destruction  to  the  action  of  the  absorb- 
ents. Mr.  Fox  supposes,  that  as  the  new  teeth  begin  to 
rise  from  their  sockets,  they  come  in  contact  with,  and  press 
ui^on,  tirst,  the  partition  of  bone  intervening  between  them 
and  the  roots  of  the  temj)oraries,  and  afterwards  upon  the 
roots  themselves  ;  and  this  pressure,  he  believes,  induces 
their  absorption.  He  afterwards,  however,  admits  that 
pressure  is  not  necessary  to  their  absorption,  as  it  sometimes 
takes  place  where  there  is  none. 

Mr.  Hunter  does  not  attempt  to  explain  the  manner  of  the 
destruction  of  the  roots  of  the  temporary  teeth  in  any  other 
way  than  by  stating,  that  they  decay  off  up  to  tlie  gum. 
Fauchard  and  Bourdet  attribute  their  removal  to  the  action 
of  a  corrosive  fluid,  supplied  for  the  special  purpose.  Bunoa 
thinks  tliey  are  worn  away  by  the  rising  teeth.  Lecluse  is 
of  the  opinion  that  when  the  process  of  their  removal  be- 
gins, their  vessels  cease  to  supply  nourishing  juices,  and 


140  SHEDDING    OF   THE  TEMPOKARY   TEETH. 

that  tlicy  are  broken  up  by  a  species  of  maceration,  while 
Jourdain  thinks  it  is  both  by  abrasion  and  corrosion. 

Mr.  Bell,  as  do  indeed  almost  all  recent  writers,  adopts 
the  theory  of  Mr.  Fox,  that  the  destruction  of  the  roots  of 
the  temporary  teeth  is  the  result  of  absorption.  Laforgue, 
observing  a  fungifom  or  carneous  substance  behind  the  root 
of  the  temporary  tooth,  which,  in  fact,  had  been  noticed  by 
Bourdet,  and  supposed  by  him  to  exhale  a  fluid  possessed 
of  solvent  qualities,  gave  it  the  name  of  absorbing  apparel, 
and  assigned  to  it  the  office  of  removing  the  root  of  the  pri- 
mary tooth. 

Delabarre,  who  has  treated  this  subject  at  greater  length 
and,  apparently,  investigated  it  more  closely,  corroborates 
the  views  of  Laforgue,  and  gives  the  following  description 
of  the  manner  of  the  formation  and  function  of  the  carneous 
substance  spoken  of  by  this  author  as  the  absorbing  apparel. 
•'While  the  crown  of  the  tooth  of  replacement,"  says  Dela- 
barre, "is  only  in  formation,  the  exterior  membrane  of  the 
matrix  is  simply  crossed  by  some  blood-vessels  ;  but  as  soon 
as  it  is  completed,  the  capillaries  are  then  developed  in  a 
very  peculiar  manner,  and  form  a  tissue  as  fine  as  cobweb  ; 
from  this  tissue  the  internal  membrane^  instead  of  continu- 
ing to  be  very  delicate,  and  of  a  pale  red  color,  increases  in 
thickness  and  assumes  a  redder  hue.  As  was  before  said,  it 
is  at  the  instant  in  which  commences  the  contraction  of  the 
coats  of  the  matrix,  that  are  conveyed  from  the  gum  to  the 
neck  of  the  tooth,  that  the  plaiting  of  the  vessels,  that  en- 
ter into  their  tissue,  compose  a  body  of  a  carneous  appear- 
ance, whose  absorbents  extend  their  empire  over  all  the  sur- 
rounding parts  ;  it  is,  therefore,  the  dental  matrix  itself, 
that^  after  being  dilated  to  serve  as  a  j^protecting  envelop  to 
the  tooth,  is  contracted  to  form  not  only  this  bud-like  body 
which  we  find  immediately  below  the  milk  tooth  ;  at  the 
instant  in  which  it  naturally  falls  out,  and  whose  volume  is 
necessarily  augmented  as  odontocia  gradually  goes  on  ;  but 
also  a  carneous  mass  by  which  the  whole  is  surrounded,  and 


SHEDDING   OF   THE   TEMPORARY   TEETH.  141 

whose  thickness  is  the  more  remarkable  as  the  organ  that  it 
envelops  is  nearer  its  orifice." 

After  giving  this  description,  he  asks,  '"^Is  there  a  dis- 
solving fluid  that  acts  chemically  on  the  surrounding  parts, 
or  do  the  absorbents,  without  any  intermedial,  destroy  every- 
thing that  would  obstruct  the  shooting  up  of  the  tooth?" 
In  reply  to  this,  he  says,  '^Not  possessing  positive  proof, 
suitable  to  guide  me  in  the  decision  of  this  question,  and 
finding  those  of  others  of  little  importanccj  I  shall  not  at- 
tempt to  answer  them. ' ' 

In  pursuing  this  subject  further,  he  states  that  the  ves- 
sels of  the  temporary  tooth  often  remain  entire  in  the  midst 
of  this  carneous  (fleshy)  substance,  continue  to  convey  their 
fluids  to  the  central  parts  of  the  teeth,  whilst  the  calcareous 
ingredients  and  the  gelatine  have  been  removed,  and  that, 
at  other  times,  they  too,  are  destroyed.  The  conclusion  to 
which  he  arrives,  after  a  careful  examination  of  the  whole 
subject,  is,  that  whether  the  earthy  and  animal  parts  of  the 
roots  are  removed  by  the  absorbents  of  the  carneous  tuber- 
cle in  question  without  any  previous  change,  or  whether 
they  arc  decomposed  by  the  chemical  action  of  a  fluid  ex- 
haled from  it,  they  are  ultimately  carried  back  into  the  gen- 
eral circulating  system. 

In  proof  of  the  agency  of  the  carneous  (fleshy)  tubercle 
in  the  destruction  of  the  roots  of  the  temporary  teeth,  he 
mentions  one  fact  that  goes  very  far  to  establish  the  truth 
of  the  opinion,  and  if  his  views  be  correct,  will  account  for 
those  cases  which  are  occasionally  met  with,  where  one  or 
more  of  the  permanent  teeth  fail  to  appear.  It  is  this  :  if 
this  substance  fajils  to  be  developed,  or  is  destroyed,  the 
tooth  remains  in  its  socket,  and  never  makes  its  appear- 
ance. Cases  of  this  kind  have  fallen  under  the  notice  of 
almost  every  dentist. 

In  as  few  words  as  possible  we  have  given  the  views  of 
this  ingenious  writer  on  the  subject  under  consideration,  and 
although  they  do  not  seem  to  have  attracted  much  attention 
from  English  writers,  and  are  rejected  by  Mr.  Boll,  on  the 


142  SHEDDING   OF   THE   TEMPORARY   TEETH. 

ground,  as  lie  says,  but  which  we  have  never  known  to  be 
the  case,  that  the  destruction  of  the  root  of  the  temporary 
frequently  commences  on  a  part  ''the  most  remote  from  the 
sac  of  the  permanent  tooth,"  we  are  disposed  to  believe  them, 
for  the  most  part,  correct.  As  to  the  existence  of  the  fleshy 
tubercles,  there  can  be  no  question,  and  that  it  is  through 
the  agency  of  these  that  the  roots  of  the  temporary  teeth 
are  destroyed,  seems  more  than  probable.  But,  whether  it 
is  througli  the  agency  of  their  absorbent  vessels  or  a  chemi- 
cal fluid  exhaled  for  the  purpose,  may  not,  as  Delabarre 
says,  be  so  easy  to  determine.  We  are  inclined  to  believCj 
however,  that  the  latter  agent  is  the  one  principally  con- 
cerned in  effecting  their  destruction,  and  for  the  reason  that 
if  litmus  paper  be  applied  to  the  fleshy  tubercle,  immediately 
the  crown  of  a  temporary  tooth  has  fallen  out  or  been  re- 
moved, it  turns  red,  thus  showing  the  presence  of  an  acid. 
That  the  absorbents  have  something  to  do  in  this  operation 
of  the  economy,  is,  we  think,  very  probable,  but  we  believe 
the  operation  of  these  delicate  vessels  is  here  always  pre- 
ceded by  the  action  of  a  chemical  agent. 

The  change  that  takes  place  in  the  external  membrane  of 
the  sac,  as  noticed  by  Delabarre,  is  observable,  first,  on  the 
peduncle  or  chord  leading  from  it  to  the  gum  behind  the 
temporary  tooth.  It  here  becomes  thickened^  about  the  time 
the  root  of  the  new  tooth  begins  to  form,  and  assumes  a 
fleshy  appearance,  and  it  is  here  that  the  destruction  of  the 
surrounding  bone  commences,  enlarging  the  alveolo-dental 
canal,  and  gradually  removing  the  intervening  bony  parti- 
tion, and,  finally,  the  root  of  the  temporary  tooth.  The 
agency  of  this  thickened  and  fleshy  condition  of  the  exterior 
membrane  of  the  capsule,  in  the  removal  of  the  roots  of  the 
temporary  teeth,  is  rendered  more  conclusive  by  the  fact, 
that,  in  tliose  cases  where  the  roots  of  the  permanent  teeth 
have  become  partially  destroyed,  the  alveolo-dental  perios- 
teum presents  a  similar  appearance.  In  the  formation,  too, 
of  alveolar  abscess,  the  tubercle  at  the  extremity  of  the  root 
presents  a  like  aspect.     There  also  seems  to  be,  in  this  in- 


< 


SHEDDING   OF  THE  TEMPORARY   TEETH.  143 

teresting  operation  of  the  economy,  an  association  of  func- 
tions mutually  dependent  upon  each  other,  so  that^  if  one 
be  suspended,  the  others  fail  to  be  performed.  Thus,  if  from 
any  cause, 'the  sac  fails  to  contract^  the  fleshy  tubercle  is  not 
developed,  nor  does  the  formation  of  the  root  take  place — 
consequently,  the  crown  of  the  tooth  remains  in  its  alveo- 
lus. Harmonious  consent  of  associated  actions  are  nowhere 
more  beautifully  exemplified,  than  in  these  three  operations 
of  the  economy. 

It  often  happens,  that  the  root  of  a  temporary  tooth  fails 
to  be  destroyed,  and  that  the  crown  of  the  replacing  organ 
comes  through  the  gum  in  a  wrong  place.  Whenever  this 
occurs,  the  carneous  body  is  developed  only  beneath  the 
parts  through  the  opening  of  which  the  new  tooth  has  ap- 
peared, and  is  not  brought  in  contact  with  the  bony  parti- 
tion, between  it  and  the  root  of  the  temporary  tooth. 

The  manner  of  the  destruction  of  the  roots  of  the  tempo- 
rary teeth  has  been  a  subject  of  careful  inquiry  with  the  au- 
thor for  several  years,  and  the  more  he  has  examined  it, 
the  more  fully  has  he  become  convinced,  that  it  is  the  re- 
sult of  the  action  of  this  fleshy  tubercle.  And  while  its 
formation  seems  to  be  the  result  of  the  contraction  of  the 
dental  sac  and  its  appendage,  for  the  purpose  of  effecting 
the  eruption  of  the  tooth,  it  is  especially  charged  with  the 
removal  of  everything  that  would  obstruct  its  passage. 

In  conclusion,  it  is  only  necessary  to  observe,  that  the 
temporary  teeth  are  shed  in  the  same  order  in  which  they 
first  appear.  After  one  pair  has  been  shed,  a  sufficient  time 
usually  elapses  before  the  shedding  of  another,  for  thoso  of 
the  same  class  of  the  permanent  set  to  come  forward  and 
take  their  place.  Thus^  the  jaws  are  never  deprived,  unless 
from  some  other  cause  than  the  destruction  of  the  roots  of 
the  temporary,  of  more  than  two  teeth  in  each  jaw  at  any 
one  time. 


CHAPTER    TENTH. 

SECOND    DENTITION. 

There  are  no  operations  of  the  animal  economy  more  singu- 
lar or  interesting  tlian  those  exhibited  in  the  gradual  de- 
struction of  the  roots  of  the  temporary^  and  in  the  growth 
and  eruption  of  the  permanent  teeth.  The  time  of  life 
when  they  occur,  constitutes  an  important  epoch  in  the  his- 
tory of  every  individual. 

During  childhood,  the  alveolar  arches  form  only  about 
the  half  of  a  circle,  but  by  the  gradual  elongation  of  the  jaws 
they  ultimately,  at  adult  age,  form  nearly  the  half  of  an 
ellipsis,  so  that  the  number  of  teeth  required  to  fill  them  at 
the  one  period,  is  but  little  more  than  half  the  number  re- 
quired at  the  other. 

Moreover,  the  food  of  children  is  principally  vegetable^ 
requiring  but  little  mastication  to  prepare  it  for  the  stomach, 
whereas,  that  of  adults,  consists  of  an  almost  equal  addi- 
tional portion  of  animal,  which,  owing  to  the  greater  cohe- 
sion of  its  particles,  require  a  more  numerous  and  substan- 
tial set  of  instruments  for  its  trituration. 

So  admirable  is  the  economy  of  second  dentition,  that 
even  before  the  shedding  of  the  temporary  teeth  commences, 
and  as  soon  as  tlie  jaws  are  sufficiently  enlarged,  four  of  the 
second  set,  one  on  each  side,  in  each  maxilla,  make  their 
appearance.  Consequently,  the  number  of  teeth,  after  the 
completion  of  the  first  set,  is  never  diminished,  unless  by 
accident  or  disease. 

The  rudiments  of  the  permanent  incisors  and  cuspidati 
have  attained  their  full  size  at  birth,  and  each  is  situated 
immediately  behind  its  corresponding  temporary  tooth. 


SECOND   DENTITION.  145 

Tbe  permanent  teeth,  witli  the  exception  of  the  bicuspids, 
are  considerably  larger  than  the  temporary,  and  during  the 
time  of  their  formation  are  situated  in  the  segment  of  a  much 
smaller  circle.  But  before  the  shedding  of  the  first  begins, 
the  latter,  by  an  increase  in  the  depth  of  the  jaws,  and  the 
development  of  the  alveolar  processes,  are  brought  forward, 
and  at  about  the  fifth  year,  they  are  situated  immedi- 
ately below  in  the  lower  and  nearly  above  in  the  upper 
maxilla,  occupying  places  in  the  alveolar  border,  correspond- 
ing in  depth  to  the  length  of  their  respective  roots. 

By  this  arrangement  the  permanent  teeth  occupy  the 
smallest  possible  space  in  the  jaws.  The  central  incisors 
and  cuspidati  nearly  fill  the  anterior  part  of  the  arch,  while 
the  lateral  are  thrown  back  behind  and  partly  between 
them. 

The  following  concise  description  of  the  relative  position 
of  the  teeth,  at  the  fifth  year  after  birth,  is  given  by  Mr. 
Bell.  "In  the  uj^per  jaw,  the  central  incisors  are  situated, 
immediately  beneath  the  nose,  the  lateral  incisors  thrown 
back. behind  the  points  of  the  cuspidati ;  and  the  base  of  the 
latter  scarcely  a  quarter  of  an  inch  below  the  orbit.  In  the 
lower  jaw,  the  cuspidati  are  placed  at  the  very  base  of  the 
bone,  with  only  a  thin  layer  beneath  them,  but  the  crowd- 
ing is  much  less  considerable  than  in  the  upper  jaw,  from 
the  smaller  comparative  size  of  the  incisors. 

"Tlie  permanent  central  incisor  of  the  lower  jaw  is  placed 
immediately  beneath  the  temporary,  with  its  point  directed 
a  little  backwards,  behind  the  partially  absorbed  root  of  the 
latter.  The  lateral  incisor,  not  yet  so  far  advanced,  is 
placed  deeper  in  the  jaw,  and  instead  of  being  immediately 
beneath  the  temporary  is  situated  with  its  point  between  the 
roots  of  this  and  the  cuspidatus.  The  permanent  cus- 
pidatus  is  still  very  deeply  imbedded  in  the  bone,  with 
its  point  resting  between  the  roots  of  the  temporary 
cuspidatus,  and  the  first  temporary  molar.  The  two 
spreading  roots  of  the  latter  encompass,  as  it  were, 
within  their  span,  the  first  bicuspis  ;  and  those  of  the  sec- 


146 


SECOND   DENTITION. 


ond  temi)oraiy  molar,  in  like  manner,  the  second  bicuspis. 
Nearly  a  similar  arrangement  is  found  to  exist  in  the  upper 
jaw,  except  that  the  teeth  are  altogether  more  crowded." 
Fig.  51.  In  Fig.  51  is  exhibited  a  front 

and  side  view  of  the  superior 
and  inferior  maxillary  bones, 
with  the  temporary  teeth  In  situ, 
the  outer  wall  of  the  alveolar 
border  being  removed,  shows 
the  situation  of  the  crowns  of 
the  permanent  incisors,  cuspi- 
dati,  bicuspids  and  first  mo- 
lars. 

The  irritation  consequent  upon  the  eruption  of  the  per- 
manent teeth,  is  usually  very  slight,  and  with  the  exception 
of  the  dentes  sapientias,  seldom  occasions  mucli  inconve- 
nience. This  is  owing  to  the  fact,  that  when  second  denti- 
tion commences,  the  system  has  acquired  so  much  vigor  and 
strength,  as  not  to  be  easily  affected  by  slight  morbid  im- 
pressions, and  the  gums  offer,  comparatively,  little  resist- 
ance to  the  erujjtion  of  the  teeth  of  replacement,  for  when 
the  temporaries  drop  out,  the  others  are  generally  so  far 
advanced  as  almost  immediately  to  appear.  Even  when 
this  is  not  the  case,  the  cicatrix  that  forms  over  the  perma- 
nent tooth  is  of  so  spongy  a  texture  that  it  readily  yields  to 
the  action  of  the  absorbents.  The  process,  too,  is  more 
gradual,  from  six  to  eight  years  being  required  for  its  com- 
pletion, while  the  eruption  of  the  teeth  of  first  dentition  is 
accomplished  in  less  than  half  that  time. 

Second  dentition  usually  commences  at  about  six  or  seven 
years  after  birth,  and  is  generally  completed,  as  far  back  as 


Fig.  51.  A  view  of  the  superior  and  inferior  maxillary  bones  of  a  child  about 
four  years  old,  with  their  exterior  and  outer  walls  removed,  so  as  to  show  the 
crowns  of  the  permanent  teeth  behind  the  roots  of  the  temporary.  The  superior 
maxillary  bones  are  separated  at  the  median  line,  and  about  a  quarter  of  an  inch 
apart.  Behind  the  second  temporary,  are  seen  the  crowns  of  the  first  permanent 
teeth  imbedded  in  the  alveolar  ridge. 


ERUPTION   OF   THE   PERMANENT   TEETH.  147 

the  second  molars,  by  the  twelfth  or  fourteenth  year.  The 
dentes  sapientige  seldom  appear  before  the  eighteenth  or 
twentieth.  The  periods  for  the  eruption  of  the  adult  teeth 
are,  however^  so  variable,  that  it  is  impossible  to  state  them 
with  perfect  accuracy.  Sometimes  the  first  permanent 
molars  appear  at  four  years,  and  the  central  incisors  at  five, 
at  other  times,  these  teeth  do  not  appear  before  the  ninth  or 
tenth  year. 

But  as  it  is  of  some  importance  that  the  periods  of  the 
eruption  of  the  several  classes  of  the  permanent  teeth  should 
be  knoAvn,  we  will  state  them  with  as  much  accuracy  as 
possible. 


First  molars,         from 

5  to    6  J 

Central  incisors,      '• 

6  to    8 

Lateral  incisors,      " 

7  to    9 

First  bicuspids,        " 

9  to  10 

Second  bicuspids,    "" 

10  to  11^ 

Cuspidati,                 " 

11  to  12 

Second  molars,        " 

12  to  14 

Third  molars,  (dentes  sapientife,) 

1*7  to  21 

But,  as  before  stated,  the  periods  for  the  eruption  of  the 
permanent  teeth,  like  those  of  the  temporary,  are  exceed- 
ingly variable.  The  cuspidati  often  appear  before  the 
second  bicuspids^  and  in  some  cases,  the  dentes  sapientiae 
not  until  the  thirtieth  or  even  fortieth  year,  and  sometimes 
they  never  show  themselves. 

The  author  is  acquinted  with  a  gentleman  who  did  not 
shed  his  left  superior  cuspidatus  until  he  was  twenty.  A 
few  months  after,  the  permanent  cuspidatus  made  its  ap-- 
pearance.  In  fact,  he  has  known  the  temporary  cuspids  in 
several  instances  to  remain  until  the  fortieth  year,  but  when 
shed  at  this  late  age  they  are  rarely  replaced.  In  the  Gen- 
eral Archives  of  Medicine  for  June,  1840,  the  case  of  a 
woman  is  recorded,  who,  at  the  age  of  forty-three,  erupted 
four  permanent  incisors,  behind  the  temporary,  which,  up 
to  this  period,  had  not  been  shed.     Four  molars  made  their 


148  ACCRETION    OF   THE   JAWS. 

appearance  a  year  later,  and  M.  Desirabode  says  he  has  met 
with  similar  cases. 

Maury  fixes  the  period  for  the  eruption  of  the  four  first 
molars  at  from  six  to  eight  years,  and  Desirabode  at  from 
six  to  seven,  but  we  have  rarely  known  them  to  delay  their 
appearance  beyond  the  sixth  year.  Both  of  these  authors, 
too,  place  the  cuspidati,  in  the  order  of  the  eruption  of  the 
teeth,  before  the  second  bicuspids. 

ACCRETION   OF   THE   JAWS. 

As  the  rudiments  of  the  temporary  teeth  increase  in  size, 
a  corresponding  increase  in  the  maxillary  bones  takes  place, 
but  during  the  earlier  stages  of  the  formation  of  the  perma- 
nent teeth  their  growth  is  not  so  manifest.  At  about  two 
and  a  half  years  after  birth,  they  begin  to  elongate,  and 
generally,  at  the  fifth  year,  have  acquired  sufficient  length 
to  admit  behind  the  second  temporary,  the  first  permanent 
molars.  After  the  completion  of  first  dentition,  the  part 
of  the  alveolar  border  occupied  by  this  set  of  teeth,  aug- 
ment in  dimensions  but  very  little.  The  increase,  after 
this  time,  is  chiefly  confined  to  the  back  part  of  the  jaw, 
between  the  second  temporary  molars  and  the  coronoid  pro- 
cesses in  the  lower,  and  the  maxillary  tuberosities  in  the 
upper.  The  anterior  part  of  the  jaws  do,  however,  augment 
a  little,  although  so  inconsiderable  in  extent,  is  the  in- 
crease here,  that  some,  and  among  whom  are  Hunter  and 
Fox,  have  been  induced  to  deny  the  fact.  By  the  admeas- 
urement of  various  jaws,  at  different  ages,  the  writers  just 
named  have  endeavored  to  prove,  that  the  larger  size  of  the 
permanent  than  the  temporary  incisors,  is  not  greater  than 
the  larger  dimensions  of  the  temporary  molars  than  the 
bicuspids,  and  that,  consequently,  no  increase  in  this  part 
of  the  jaw  is  necessary. 

But  a  measurement  of  the  same  jaw,  made  after  the  first 
permanent  molars  have  come  through  the  gums,  then  again 


ACCRETION    OF   THE   JAWS.  149 

after  the  eruption  of  all  the  teeth  of  replacement,  will  show 
that  their  measurements  are  not  to  be  relied  on. 

M.  Delabarre,  in  attempting  to  prove  the  incorrectness  of 
these  gentlemen's  calculations,  by  a  similar  course  of  exper- 
iments, appears  to  have  fallen  into  an  opposite  error, 
whence,  it  Avould  seem,  as  is  justly  remarked  by  Mr.  Bell, 
"That  no  comparison,  instituted  between  the  jaws  of  differ- 
ent individuals,  can  be  relied  on  as  conclusive."  The  only 
way  by  which  we  can  arrive  at  the  truth  of  the  matter  is  by 
examining  the  same  jaw  at  diiferent  ages,  and  comparing 
the  several  results.  "This,"  says  Mr.  B.,  "I  have  repeat- 
edly done,  and  have  no  hesitation  in  saying,  that  the  ten 
anterior  permanent  teeth  occupy  a  somewhat  larger  arch 
than  the  temporary  ones  which  precede  them  had  done." 
The  transverse  and  perpendiculr  dimensions  of  the  ante- 
rior part  of  the  jaws  continue  to  augment  until  the  comple- 
tion of  second  dentition. 

In  alluding  to  the  influence  which  the  pressure  of  the 
teeth  has  in  determining  an  increase  of  the  anterior  part  of 
the  jaws,  Delabarre  contends,  that  while  it  is  impossible  for 
there  to  be  any  immediate  pressure  of  these  organs,  except 
at  the  time  when  they  are  forcing  their  way  through  the 
enlarged  alveolo-dental  canals,  their  contact,  at  this  period, 
gives  rise  to  a  mechanical  increase  ;  and  he  believes  that 
previously  to  this  period,  the  enlargement  is  carried  on  by 
the  liquor  contained  in  the  dental  sacs.  He  argues,  there- 
fore, that  the  jaws,  besides  the  mode  of  accretion  resulting 
from  nutrition  "have  another,  peculiar  to  themselves," 
coinciding  with  the  development  of  the  dental  sacs,  and  the 
quantity  of  fluid  which  they  contain,  as  also  with  the  man- 
ner of  the  arrangement  of  the  crowns  of  the  permanent  teeth 
between  such  as  may  be  in  the  circle,  whether  belonging  to 
first  or  second  dentition. 

That  the  dimensions  of  the  alveolar  arch  may  be  increased 
by  pressure  upon  the  teeth  from  behind  forwards,  no  one 
will  deny,  but  to  suppose  the  accretion  of  the  jaws  may  be 
determined  by  the  pressure  of  these  organs  against  each 


150  ACCRETION    OF   THE   JAWS. 

other,  or  by  the  fluid  contained  in  the  dental  sacs,  would  he 
to  suppose  that  tlie  law  that  determines  it  in  other  hones,  is 
inoperative  here.  In  fact,  to  do  this,  would  be  attributing 
it  rather  to  accident  than  to  a  natural  operation  of  the 
economy.* 

The  eh)ngation  of  the  jaws  produce  a  corresponding- 
change  in  the  form  of  the  face.  Thus,  the  face  of  a  child  is 
round,  that  of  an  adult  is  long  and  prominent. 

The  permanent  incisors  usually  fill  the  space  formerly 
occupied  by  the  temporaries  of  the  same  cLass,  and  about 
one-half  of  that  previously  filled  by  the  primitive  cuspids. 
The  other  half  of  this  space,  together  with  a  moiety  of  that 
before  taken  up  by  the  first  temporary  molars,  is  occupied 
by  the  permanent  cuspids. 

The  bicuspids  occupy  larger  spaces,  by  one-fifth  or  sixth, 
than  those  occupied  by  the  remaining  moities  of  the  first, 
and  the  whole  of  the  second  temporary  molars. 

Hence,  it  will  be  perceived,  that  the  ten  anterior  perma- 
nent teeth  occupy  a  somewhat  larger  space  than  that  taken 
up  by  the  temporary  ones  which  preceded  them,  and  that, 
were  there  no  increase  in  the  size  of  this  portion  of  the  arch, 
the  regularity  of  their  arrangement  would  be  more  or  less 
disturbed.  To  prevent  this  a  slight  increase,  is  necessary, 
but  the  dimensions  of  that  portion  of  the  alveolar  border 
occupied  by  tlie  temporary  teeth  is  not  materially  increased 
until  these  teeth  are  shed,  and  then,  as  those  of  replacement 
come  forward  to  take  their  place,  they  arrange  themselves 


*  The  formation  of  the  alveolar  processes,  and  that  of  the  teeth,  take  place  ac- 
cording to  different  laws.  The  jaws  grow  and  enlarge  in  conformity  with  the  gen- 
eral laws  which  preside  over  the  increase  of  the  osseous  system.  The  alveolar 
arches,  at  birth,  are  little  more  than  one  inch  in  length  ;  at  nine  years  of  age,  they 
are  nearly  two  inches,  and  at  the  period  of  perfect  growth,  at  least  two  inches  and 
a  half  long.  The  depth  of  the  lower  jaw  in  the  fetus  at  the  full  time  is  the  seventh, 
and  in  the  adult  the  fifth  of  the  whole  height  of  the  head.  The  teeth,  on  the  con- 
trary, uniformly  appear  with  the  breadth  and  thickness  only,  not  the  length,  to 
which  they  will  ever  attain.  In  order  that  the  development  of  these  organs  may 
take  place  in  a  regular  manner,  it  is,  therefore,  necessary  that  a  certain  harmony 
be  established  between  their  sizes  at  different  periods,  and  the  alveolar  edges  of  the 
jaws. — Bourrjery's  Anatomy. 


ACCRETION   OF   THE   JAWS.  151 

in  a  somewhat  larger  arcli.  It  is  by  this  oj^eration  of 
the  economy  that  the  size  of  the  alveolar  border  is  aug- 
mented. In  fact,  a  new  alveolar  ridge  is  formed,  and  this 
last  is  slightly  larger  than  the  first. 

But  there  is  not  always  an  increase  in  the  anterior  part 
of  the  jaws  ;  on  the  contrary,  the  premature  loss  of  one  or 
more  of  the  temporary  teeth  often  occasions  a  contraction 
that  frequently  causes  irregularity  of  the  permanent  set, 
and  sometimes  forces  the  first  and  second  molars  so  far  back^ 
that  the  dentes  sapientias  are  thrown  against  the  coronoid 
processes,  and  thus,  in  many  instances,  jDroducing  such  se- 
vere inflammation  in  the  muscles  of  this  portion  of  the  jaw, 
that  the  extraction  of  these  latter  teeth  is  rendered  absolute- 
ly necessary. 

About  the  third  year,  the  jaws  are  more  rapidly  elonga- 
ted, in  order  that  the  first  permanent  molars,  which  are  at 
this  time  slowly  advancing,  may  find  room  behind  the 
second  temporary  molars.  This  elongation  continues  until 
the  dental  arches  have  become  sufficiently  enlarged  for  the 
reception  of  the  whole  of  the  permanent  teeth. 

It  sometimes  happens  that  the  jaws  in  their  accretion  are 
badly  developed,  and  have  a  faulty  configuration.  This 
may  occur  with  one  or  both  jaws.  The  alveolar  aich  is 
sometimes  too  narrow,  having  a  compressed  appearance, 
and  projecting  so  far  forward  as  to  prevent  the  upper  lip 
from  covering  the  front  teeth,  thus  imparting  to  the  indi- 
vidual an  exceedingly  disagreeable  appearance.  In  cases 
of  this  sort,  the  roof  of  the  mouth,  instead  of  having  an  oval 
arch,  presents  an  irregular  triangle.  At  other  times  the 
alveolar  arch  is  too  wide,  so  that  the  teeth  are  separated 
from  each  other,  giving  to  the  roof  of  the  mouth  a  flattened 
aspect. 

Similar  defects  are  met  with  in  the  configuration  of  the 
lower  jaw.  Its  sides  may  be  too  close  together,  causing  the 
front  teeth  to  project  and  to  cross  and  strike  on  the  outside 
of  the  upper  incisors,  or  it  may  describe  too  large  a  circle. 

These  defects  are  regarded  as  hereditary,  and  are  more 


152  ACCRETION   OF   THE   JAWS. 

peculiar  to  some  nations  than  otlieis.  The  tendency  to 
them  is  observable  in  early  childhood,  and  even  in  infancy. 
Many  suppose  they  are  determined  by  a  rickety  diathesis 
of  the  general  system,  but  this  opinion  has  been  proven  to 
be  incorrect  by  the  iact,  that  those  affected  with  this  disease 
generally  have  good  .palates  and  w^ell  developed  jaws.  So 
far,  indeed,  from  its  having  any  agency  in  their  production, 
rickets  is  thought  by  some  to  be  produced  by  dentition^,  as- 
signing as  a  reason  for  this  belief,  its  frequent  occurrence  at 
the  i^eriod  of  life,  when  this  process  is  going  on  ;  but  this 
ojiinion  is  doubtless  as  incorrect  as  is  the  other  and  opposite 
one.  These  jjcculiarities  in  the  formation  of  the  jaws  no 
doubt,  often  result  as  a  consec[uence  of  the  intermarriage  of 
the  people  of  one  nation  with  those  of  another.  The  upper 
jaw  will  resemble  in  shape  and  size  that  of  the  father,  and 
the  lower  that  of  the  mother,  or,  vice  versa. 

There  is  a  species  of  deformity  in  the  upper  jaw,  the 
cause  of  which  is  equally  difficult  of  explanation,  character- 
ized by  one  or  more  divisions  of  the  upper  lip,  alveolar  ridge 
and  palatine  arch,  and  necessarily  accompanied  by  irregu- 
larity in  the  arrangement  of  the  teeth.  This  deformity  is 
always  congenital,  and  often  exceedingly  difficult  to  remedy. 

Any  infringement  of  the  laws  of  growth,  or  disturbance  of 
the  functional  operations  of  any  of  the  organs  of  the  face  or 
head,  may,  we  have  no  doubt,  determine  an  improper  de- 
velopment of  the  jaws  and  a  bad  arrangement  of  the  teeth  ; 
on  the  other  hand,  a  perfect,  correct  and  healthful,  perform- 
ance of  the  several  functions  of  all  the  parts  concerned  in  the 
formation  and  growth  of  this  portion  of  the  organism,  will 
secure  a  natural  development  and  configuration  of  the  max- 
illary bones. 


CHAPTER     ELEVENTH. 

METHOD   OF  DIRECimG  SECOND  DENTITIOX. 

Theee  is  nothing  more  destructive  to  tlie  Leauty,  liealtli 
and  durability  of  the  teeth,  and  no  disturbance  more  easily 
prevented,  than  irregularity  of  their  arrangement.  In 
proportion,  too,  to  the  deviation  of  these  organs  from  their 
proper  position  in  the  alveolar  arch^  are  the  features  of  the 
face  and  the  expression  of  the  countenance  injured.  It 
also  increases  the  susceptibility  of  the  gums  and  alveolo- 
dental  membranes  to  morbid  impressions. 

It  is  important,  therefore,  that  the  mouth  during  second 
dentition,  should  be  properly  cared  for  ;  and  so  thoroughly 
convinced  is  the  author  of  this,  that  he  does  not  hesitate  to 
say,  that  if  timely  precautions  were  used,  there  would  not 
be  one  decayed  tooth  where  there  are  now  a  dozen. 

Much  harm,  it  is  true,  may  be  done  by  improper  med- 
dling with  the  teeth  during  this  period,  but  this  so  far 
from  inducing  a  total  neglect,  should  only  make  those  having 
the  care  of  children  more  careful  to  secure  the  services  of 
scientific,  accomplished  practitioners. 

For  the  judicious  management  of  second  dentition,  much 
judgment  and  a  correct  knowledge  of  the  normal  periods  of 
the  eruption  of  the  several  classes  of  teeth,  are  required. 
All  unnecessary  interference  with  these  organs,  at  this  early 
period  of  life,  should  certainly  be  avoided,  as  it  will  only 
tend  to  mar  the  jDerfection  at  which  nature  ever  aims.  The 
legitimate  duty  of  the  physician  being,  as  Mr,  Bell  correct- 
ly observes,  'Hhe  regulation  of  the  natural  functions  when 
deranged  ;"  he  should  never  anticipate  the  removal  by  na- 
ture, of  the  temporary  teeth,  unless  their  extraction  is  called 
11 


154  METHOD   OF   DIRECTING   SECOND   DENTITION. 

for  by  some  pressing  emergency,  such  as  a  deviation  of  the 
permanent  ones  from  their  proper  phice,  alveolar  abscess^  or 
exfoliation  of  the  alveolar  processes. 

Among  the  few  who  have  treated  this  subject  in  a  full  and 
philosophical  manner,  we  will  mention  Delabarre,  whose 
work  contains  the  most  explicit  directions  in  regard  to  it  of 
any  that  have  as  yet  ajipearcd.  Owing  to  the  superficial 
manner  in  which  second  dentition  is  frequently  studied,  this 
author  was  led  to  remark,  "That  the  laws  which  govern  the 
expansion,  growth  and  arrangement  of  the  teeth,  are  prop- 
erly the  patrimony  of  the  physician,  who  should  under- 
stand tliem,  in  order  to  direct  the  dentist,  whenever  (which 
unfortunately  is  very  frequently  the  case)  he  is  not  furnished 
with  sufficient  inlorraation  on  all  the  duties  of  his  profes- 
sion." That  this  was  necessary  at  the  time  Delabarre 
wrote,  cannot  be  doubted  ;  but  at  present  we  have  many 
men  in  the  dental  profession  better  qualified  to  judge  of 
what  is  required  in  cases  of  this  sort  than  any  general 
practitioner  whose  attention  has  never  been  specially  di- 
rected to  this  peculiar  department  of  practice. 

The  mouth  should  be  frequently  examined  from  the  time 
the  shedding  of  the  deciduous  teeth  commences  until  the 
completion  of  second  dentition  ;  and  when  the  growth  of  the 
permanent  teeth  so  far  outstrips  the  destruction  of  the  roots 
of  the  temjiorary,  that  the  former  arc  caused  to  take  an  im- 
proper direction^  such  of  the  latter  as  have  occasioned  the 
obstruction,  should  be  immediately  removed.  In  the  den- 
tition of  the  upper  front  teeth,  this  should  never  be  neg- 
lected ;  for,  when  they  come  out  behind  the  temporaries,  as 
they  most  frequently  do,  and  are  permitted  to  advance  so 
far  as  to  fall  on  the  inside  of  the  lower  incisors,  a  perma- 
nent obstacle  is  offered  to  their  subsequent  proper  adjust- 
ment. 

When  a  wrong  direction  has  been  given  to  the  growth  of 
the  lower  front  teetli,  they  are  rarely  prevented  from  ac- 
quiring their  proper  arrangement  by  au  obstruction  of  this 
sort.     They  should  not,  however,  on  this  account,  be  per- 


METHOD    OF   DIRECTING   SECOND   DENTITION,  155 

mitted  to  occupy  a  wrong  position  too  long,  for  the  evil  will 
be  found  easier  of  correction  while  recent,  than  after  it  has 
continued  for  a  considerable  length  of  time.  The  irregu- 
larity should  be  immediately  removed. 

The  permanent  central  incisors  of  the  upper  jaw  being 
larger  than  the  temporaries  of  the  same  class,  it  might, 
therefore,  be  supposed,  that  the  aperture  formed  by  the  re- 
moval of  the  one,  would  not  be  sufficient  for  the  admission 
of  the  other,  without  an  increase  in  the  size  of  this  part  of 
the  maxillary  arch.  It  should  be  recollected,  however,  that 
by  the  time  these  teeth  usually  emerge  from  the  gums,  the 
crowns  of  the  temporary  lateral  incisors  are  so  much  loosen- 
ed by  the  partial  destruction  of  their  roots,  as  to  yield  suffi- 
ciently to  the  pressure  of  the  former,  to  permit  them  to  take 
their  proper  position  within  the  dental  circle.  When  this 
does  not  liappen,  the  temporary  laterals  should  be  extracted. 

Under  similar  circumstances,  the  same  course  should  be 
pursued  with  the  permanent  lateral  incisors  and  the  tem- 
porary cuspids,  and  also  with  the  permanent  cuspids  and 
the  first  bicuspids. 

The  bicuspids  being  situated  between  the  fangs  of  the 
temporary  molars,  are  seldom  caused  to  take  an  improper 
direction  in  their  growth.  Nor  are  they  often  prevented 
from  coming  out  in  their  proper  place  for  want  of  room. 

In  the  management  of  second  dentition,  much  will  depend 
on  the  exi)erience  and  judgment  of  the  practitioner.  If  he 
be  properly  informed  upon  tlie  subject,  and  gives  to  it  the 
necessary  care  and  attention,  the  mouth  will,  in  most  in- 
stances, be  furnished  with  a  healthy,  well  arranged  and 
beautiul  set  of  teeth.  At  this  time,  "an  opportunity," 
says  Mr.  Fox,  ""presents  itself  for  effecting  this  desirable 
object,"  (the  prevention  of  irregularity,)  "but  every  thing 
depends  upon  a  correct  knowledge  of  the  time  when  a  tooth 
requires  to  be  extracted,  and  also  of  the  particular  tooth, 
for  often  more  injury  is  occasioned  by  the  removal  of  a  tooth 
too  early  than  if  it  be  left  a  little  too  long  ;  because  a  new 
tooth,  which  has  too  much  room  long  before  it  is  required, 


156  METHOD   OF   DIRECTING   SECOND   DENTITION. 

will  sometimes  take  a  direction  more  difficult  to  alter,  than 
a  slight  irregularity  occasioned  by  an  obstruction  of  short 
duration." 

Mr.  Bell  objects  to  the  extraction  of  the  temporary  teeth, 
especially  in  the  lower  jaw,  to  make  room  for  the  permanent, 
on  the  ground  that  the  practice  is  harsli  and  unnatural — 
that  it  often  gives  rise  to  a  contraction  of  the  maxillary 
arch,  and  that,  in  consequence  of  the  peduncular  connection 
that  exists  between  the  necks  of  the  temporary  teeth  and  the 
sacs  of  the  permanent  ones,  it  interferes  with  the  uniform 
deposition  of  the  enamel. 

These  objections,  if  the}'  were  well  founded,  should  deter 
every  dentist  from  adopting  the  practice,  except  as  a  dernier 
resort — as  the  least  of  two  evils.  But  when  the  temporary 
teeth,  by  remaining  too  long,  are  likely  to  aiiect  the  ar- 
rangement, and,* consequently,  the  health  of  the  permanent 
teeth,  they  should  be  extracted  ;  because,  in  that  case,  their 
presence  is  a  greater  evil  than  any  that  would  be  occasioned 
by  their  removal.  This  last  objection  is  founded  upon  a 
false  assumption,  but  on  other  grounds  it  may  often  be  very 
properly  urged.  But  as  a  general  rule,  they  should  be  suf- 
fered to  remain  until  their  presence  is  likely  to  injure  the 
permanent  teeth  and  their  contiguous  parts. 

When  the  iDcrmanent  teeth  are  crowded,  the  lateral  pres- 
sure is  frequently  so  great  as  to  fracture  the  enamel.  If  this 
cannot  be  prevented  in  any  other  way,  one  on  each  side 
should  be  extracted.  It  is  better  to  sacrifice  two  than  per- 
manently to  endanger  the  health  of  the  whole. 

M.  Delabarre,  in  cases  where  the  crowding  is  not  very 
great,  recommends  passing  a  file  between  the  teeth,  as  does 
also  Mr.  Bell,  when  only  the  space  usually  occupied  by  half 
of  a  tooth  is  required. 

Notwithstanding  the  deservedly  high  authority  of  these 
two  gentlemen,  the  author's  experience  compels  him  to  con- 
demn the  practice.  The  apertures  thus  formed  soon  close^ 
but  not  so  perfectly  as  to  prevent  small  particles  of  extra- 
neous matter  from  lodging  between  the  teeth,  and  being  re- 


METHOD    OF   DIRECTING  SECOND    DENTITION.  157 

tained  there  until  they  become  putrid,  vitiating  the  mucous 
and  salivary  secretions  of  the  mouth,  and  thus  causing  the 
teeth  to  decay.  In  this  manner,  he  has  sometimes  known 
the  front  teeth  to  he  entirely  destroyed  ;  and  he  has  always 
observed,  that  teeth  which  had  been  thus  filed,  were  inva- 
riably the  first,  and  sometimes  the  only  ones,  to  decay — 
thus  clearly  pointing  out  the  pernicious  tendency  of  the 
practice. 

He  does  not,  however,  wish  to  be  understood  as  convey- 
ing the  idea  that  filing  the  teeth  necessarily  causes  them  to 
decay,  for,  when  the  file  is  used  for  any  other  purpose  than 
to  gain  room,  the  apertures  may  be  made  large  enough  to 
prevent  the  approximation  of  the  organs,  and  thus  the  bad 
effects  resulting  from  the  operation  will  be  prevented. 

The  file  should  never  be  used,  therefore,  with  a  view  to 
remedy  irregularity  ;  the  extraction  of  two  teeth,  one  on 
each  side  of  the  jaw,  however  small  the  space  required  to  be 
gained  may  be,  is  far  preferable.  The  second  bicuspids, 
ceteris  parabus,  should  always  be  removed  rather  than  the 
first,  but  sometimes  the  extraction  of  the  first  becomes  ne- 
cessary. 

By  the  removal  of  two,  ample  room  will  be  gained  for  the 
arrangement  of  all  the  remaining  teeth,  and  the  injury  re- 
sulting from  a  crowded  condition  of  the  organs  prevented. 

On  filing  teeth,  to  prevent  irregularity.  Dr.  Fitch  judi- 
ciously remarks  :  ''I  consider  the  expediency  of  filing  or  not 
filing  the  teeth^  ought  to  be  a  subject  of  serious  deliberation 
on  the  part  of  the  dental  practitioner,  and  never^  especially 
in  young  persons,  perform  the  operation,  unless  obliged  to 
do  so,  to  cure  actual  disease. 

"I  was  greatly  surprised,  in  the  late  work  of  Mr.  Bell,  to 
see  directions  to  file  slightly  irregular  and  crooked  teeth,  so 
as  to  gain  about  half  a  tooth  of  room." 

Nature,  when  permitted  to  proceed  with  her  work  with- 
out interruption,  is  able  to  perform  her  operations  in  a  per- 
fect and  harmonious  manner.  But  the  functional  opera- 
tions of  all  the  parts  of  the  body  are  liable  to  be  disturbed 


158  METHOD   OF   DIRECTING  SECOND   DENTITION. 

from  an  almost  innumerable  number  and  variety  of  causes, 
and  impairment  of  one  organ  often  gives  rise  to  derange- 
ment of  the  whole  organism.  For  the  relief  of  which,  the 
interposition  of  art  not  unfrequently  becomes  necessary,  and 
it  is  fortunate  for  the  well  being  of  man,  that  it  can,  in  so 
many  instances,  be  applied  with  success. 

In  sound  and  healthy  constitutions,  the  services  of  the 
dentist  are  seldom  required  to  assist  or  direct  second  denti- 
tion. In  remarking  upon  this  subject,  Dr.  Koecker  ob- 
serves, "that  the  children,  for  whom  the  assistance  of  the 
dentist  is  most  frequently  sought,  are  those  who  are  either 
in  a  delicate,  or  at  least  in  imperfect  constitutional  health  ; 
where  the  state  of  not  only  the  temporary  teeth,  but  of  the 
permanent  also,  is  to  be  considered  ;  and,  where  both  are 
found  diseased,  the  future  health  and  regularity  of  the  lat- 
ter require  the  greatest  consideration  of  the  surgeon. 

"Irregularity  of  the  teeth  is  one  of  their  chief  predisposing 
causes  of  disease,  and  never  fails,  even  in  the  most  healthy 
constitutions,  to  destroy,  sooner  or  later,  the  strongest  and 
best  set  of  teeth,  unless  properly  attended  to.  It  is  thus 
not  only  a  most  powerful  cause  of  destruction  to  the  health 
and  beauty  of  the  teeth,  but  also  to  the  regularity  and 
pleasing  symmetry  of  the  features  of  the  face  ;  always  pro- 
ducing, though  slowly  and  gradually,  some  irregularity, 
but  not  unfrequently  the  most  surprising  and  disgusting 
appearance." 

Finall}^,  we  would  remark,  that  though  nature  is  gene- 
rally able  to  accomplish  the  task  assigned  her,  yet  there  are 
times  when  she  requires  aid,  and  it  is  then,  and  then  only, 
that  the  services  of  the  dentist  are  needed.  Therefore, 
whilst,  on  the  one  hancl_,  we  should  guard  against  any  un- 
called for  interference,  we  should,  on  the  other,  always  be 
ready  to  give  such  assistance,  as  the  nature  of  the  disturb- 
ance presented  to  our  notice^  may  require. 


CHAPTER    TWELFTH. 

IRREGULARITY  OF  THE  TEETH. 

The  temporary  teeth  seldom  deviate  from  their  proper 
place  in  the  alveolar  arch,  but  with  the  permanent  teeth, 
irregularity  of  arrangement  is  of  frequent  occurrence.  The 
incisors  and  cuspids  are  more  liable  to  take  an  improper 
position  than  any  of  the  other  teeth.  The  first  and  second 
molars  seldom  deviate  from  their  proper  place  ;  for,  like 
the  teeth  of  first  dentition^  they  rarely  encounter  obstruction 
in  their  growth  and  eruption. 

The  first  molars  being  the  first  of  the  second  set  to 
appear,  the  ten  replacing  teeth  are  limited  to  that  part  of 
the  arch  occupied  by  the  first  set,  and  if  this  is  too  small, 
irregularity  must  of  necessity  ensue. 

The  dentes  sapientias  are  sometimes  prevented  from  com- 
ing out  in  their  proper  place  in  the  lower  jaw,  by  want  of 
room  between  the  second  molars  and  coronoid  processes  ; 
and  in  the  upper  maxillary,  by  want  of  space  between  the 
last  named  teeth  and  the  angle  of  the  jaw. 

When  a  bicuspis  is  forced  from  its  proper  place,  it  turns 
inwards  towards  the  tongue,  or  outwards  towards  the  cheek, 
according  as  it  is  in  the  upper  or  lower  jaw.  The  cuspids, 
when  prevented  from  coming  out  in  their  proper  place^ 
make  their  appearance  either  before  or  behind  the  other 
teeth.  When  they  come  out  anteriorly,  which  they  do  more 
frequently  than  posteriorly,  they  often  become  a  source  of 
annoyance  to  the  upper  lip,  excoriating  the  lining  mem- 
brane, and  sometimes  causing  ulceration. 

The  incisors  of  the  upper  jaw  jiresent  a  greater  variety  in 
the  manner  of  their  arrangement  than  any  of  the  other  teeth. 


160  IRREGULARITY  OF   THE   TEETH. 

The  centrals  sometimes  come  out  before  and  sometimes 
behind  the  arch ;  at  other  times,  their  sides,  next  the 
median  line,  are  turned  either  directly  or  obliquely  forwards 
towards  the  lip.  The  laterals  sometimes  appear  half  an 
inch  behind  the  arch,  looking  towards  the  roof  of  the 
mouth  ;  at  other  times,  they  come  out  in  front  of  the  arch, 
and  at  other  times  again,  they  are  turned  obliquely  or 
transversely  across  it. 

When  any  of  the  upper  incisors  are  very  much  inclined 
towards  the  interior  of  the  mouth,  the  lower  teeth,  at  each 
occlusion  of  the  jaws,  shut  before  them,  and  become  an  ob- 
stacle to  their  adjustment.  This  is  a  very  difficult  kind  of 
irregularity  to  remedy,  often  interfering  with  the  lateral 
motions  of  the  jaw. 

The  lower  incisors  sometimes  shut  in  this  manner  even 
when  there  is  no  deviation  of  the  upper  teeth  to  the  interior. 
In  this  case,  the  irregularity  is  owing  to  preternatural  elon- 
gation of  the  lower  jaw,  which  arises  more  frequently  from 
some  fault  of  dentition^  than  from  any  congenital  defect  in 
the  jaw  itself. 

Sometimes^  the  superior  maxillary  arch  is  so  much  con- 
tracted, and  the  front  teeth  in  consequence  so  much  project- 
ed, tliat  the  upper  lip  is  prevented  from  covering  them. 
Cases  of  this  kind,  however,  are  rarely  met  with,  but  when 
they  do  occur,  it  occasions  much  deformity  of  the  face,  and 
forms  a  species  of  irregularity  very  difficult  to  correct. 

From  the  same  cause,  the  lateral  incisors  are  sometimes 
forced  from  the  arch,  and  appear  behind  the  centrals  and 
cuspids,  the  dental  circle  being  filled  with  the  other  teeth. 

There  are  many  other  deviations  in  the  a^rrangement  of 
these  teeth.  Mr.  Fox  mentions  one  that  was  caused  by  the 
presence  of  two  supernumerary  teeth  of  a  conical  form,  sit- 
uated partly  behind  and  partly  between  the  central  incisors, 
which  in  consequence,  were  thrown  forward,  while  the 
laterals  were  placed  in  a  line  with  the  supernumeraries  ; 
the  central  incisors,  though  half  an  inch  apart,  formed  one 
low,  and  the  laterals  and  supernumeraries,  another.     Mr. 


IRREGULARITY  OF  THE  TEETH.  161 

F.  says  lie  lias  seen  tliree  cases  of  this  kind.  This  descrip- 
tion of  irregularity  is  rarely  met  with. 

M.  Delabarre  says,  that  cases  of  a  transposition  of  the 
germs  of  the  teeth  occasionally  occur,  so  that  a  lateral 
incisor  takes  the  place  of  a  central,  and  a  central  the  place 
of  the  lateral.  A  similar  transposition  of  a  cuspidatus  and 
lateral  incisor  is,  also,  sometimes  seen.  Two  cases  of  this 
sort  have  fallen  under  the  observation  of  the  author. 

The  incisors  of  the  lower  jaw,  being  smaller  than  those  of 
the  upper,  and  in  other  respects  less  conspicuous,  do  not  so 
plainly  show  an  irregularity  in  their  arrangement,  nor  is 
the  appearance  of  an  individual  so  much  affected  by  it. 
Still  it  should  be  guarded  against^  for  such  deviation, 
whether  in  the  upper  or  lower  jaw,  is  productive  of  injury 
to  the  health  of  the  teeth,  and  to  the  beauty  of  the  mouth. 

The  growth  of  the  inferior  permanent  incisors  is  some- 
times more  rapid  than  the  destruction  of  the  roots  of  the 
corresponding  temporaries.  In  this  case,  the  former  emerge 
from  the  gums  behind  the  latter,  and  sometimes  so  far  back 
as  greatly  to  annoy  the  tongue,  and  interfere  with  enuncia- 
tion. At  other  times,  the  permanent  centrals  are  prevented 
from  assuming  their  proper  place,  because  the  space  left  for 
them  by  the  temporaries  is  not  sufficient  for  their  reception. 
The  irregularity  in  the  former  of  these  two  cases,  is  greater 
than  in  the  latter.  The  same  causes,  in  like  manner  affect 
the  laterals. 

M.  Delabarre  mentions  a  defect  in  the  natural  conforma- 
tion of  the  jaws,  by  which  the  upper  temporary  incisors  on 
one  side  of  the  median  line  are  thrown  on  the  outside  of  the 
loAver  teeth,  while  the  corresponding  teeth,  on  the  other  side 
of  the  same  line,  fall  within.*     The  same  disposition,  he 


*  Eufin  il  y  a  une  espece  de  torsion  de  Tune  ou  de  I'autre  machoire,  et  queUiue- 
fois  de  toute  les  deux,  qui  fait  que  les  dents  temporaries  supcrieures  antcrieures 
recouvrent  les  inferieures,  d'apaes  la  meilleure  disposition;  tandis  qu'  a  couimencer 
de  la  linge  mcdiane,  les  semblables  dents  de  I'autre  cute,  rentrent  en  dedans  des  in- 
ferieures ;  il  est  probable,  dans  ce  cas,  que  si  Ton  n'y  obvie,  le  memo  disposition  se 
reproduira  pour  la  seconde  dentition. —  Traite  de  la  Seconds  Dentition,  p.  136. 


162  TREATMENT   OF   IRREGULARITY    OF   THE   TEETH. 

says,  may  be  expected,  unless  the  defect  is  previously  reme- 
died, after  the  dentition  of  the  permanent  teeth.  The 
author  has  never  met  with  more  than  two  cases  of  this  sort, 
and  he  did  not  see  the  subjects  of  these  until  after  they  were 
adults. 

TREATMENT. 

In  the  treatment  of  irregularity,  the  means  employed 
should  accord  with  the  indications  of  nature.  When  it  is 
neither  great  nor  complicated,  and  its  causes  are  removed 
before  the  nineteenth  or  twentieth  year^  the  teeth,  without 
the  aid  of  art,  will  in  most  cases,  soon  acquire  their  proper 
position. 

When,  however,  the  efforts  of  the  economy  are  unavail- 
ing, recourse  should  be  had  to  the  dentist,  who  can,  in 
most  instances,  bring  the  deviating  organs  to  their  proper 
position  in  the  arch. 

The  practicability  of  altering  the  position  of  a  tooth,  after 
the  completion  of  its  growth,  was  well  know  to  many  of  the 
early  practitioners,  but  as  before  the  commencement  of  the 
present  century,  the  more  particular  object  of  the  dentist, 
was,  the  insertion  of  artificial  teeth,  this  branch  of  dentistry 
met  with  little  attention.  Fauchard  and  Bourdet  were 
among  the  first  to  study  orthodontia.  They  invented  a  va- 
riety of  fixtures  for  adjusting  such  of  the  teeth  as  were  not 
rightly  arranged  ;  but  most  of  these  were  so  awkward  in 
their  construction,  and  occasioned  so  much  inconvenience  to 
the  patient,  that  they  were  seldom  employed. 

Mr.  Fox  was  among  the  first  to  give  explicit  directions 
for  remedying  irregularity  of  the  teeth,  and  his  method  of 
treatment  has  formed  the  basis  of  the  established  practice  for 
more  than  fifty  years.  This  long  trial  has  proved  it  to  be 
founded  upon  a  knowledge  of  the  laws  of  the  economy,  and 
much  practical  experience. 

In  describing  the  treatment  of  irregularity,  we  shall  no- 
tice the  means  by  which  some  of  its  principal  varieties  may 


TREATMENT   OF   IRREGULARITY   OF   THE   TEETH.  163 

be  remedied  ;  otherwise,  the  application  of  the  principles  of 
treatment  would  not  be  well  understood,  since  it  must  be 
varied  to  suit  each  individual  case. 

As  a  general  rule,  the  sooner  irregularity  in  the  arrange- 
ment of  the  teeth  is  remedied  the  better,  for  the  longer  a 
tooth  is  allowed  to  occupy  a  wrong  position,  the  more  diffi- 
cult will  be  its  adjustment.  The  position  of  a  tooth  may 
sometimes  be  altered,  after  the  eighteenth,  twentieth,  or 
even  the  thirtieth  year,  but,  it  is  better  not  to  delay  the  ap- 
plication of  the  proper  means  until  so  late  a  period  ;  for  a 
change  of  this  kind  may  be  much  more  easily  effected  before 
the  several  parts  of  the  osseous  system  have  acquired  their 
full  size,  and  while  the  process  of  new  formation  is  in  vig- 
orous operation,  than  at  a  later  period  of  life. 

The  age  of  the  subject,  therefore,  should  always  govern 
the  practitioner  in  forming  an  opinion  as  to  the  practicability 
of  removing  irregularity.  Previously  to  the  twentieth  year, 
the  worst  varieties  of  irregularity  may,  in  most  cases^  be 
successfully  treated. 

The  first  thing  claiming  attention  in  the  treatment, 
is  the  removal  of  its  causes.  Whenever,  therefore,  the 
presence  of  any  of  the  temporary  teeth  has  given  a  false 
direction  to  one  or  more  of  the  permanent,  they  should  be 
extracted,  and  the  deviating  teeth  pressed  several  times  a 
day  with  the  finger,  in  the  direction  they  are  to  be  moved. 
This,  if  the  irregularity  has  been  occasioned  by  the  presence 
of  a  deciduous  tooth,  will^  generally,  be  all  that  is  required. 

But,  when  it  is  the  result  of  narrowness  of  the  jaw,  either 
natural  or  acquired,  a  permanent  tooth  on  either  side 
should  be  removed,  to  make  room  for  such  as  are  improper- 
ly situated.  All  the  teeth  being  sound  and  well  formed, 
the  second  bicuspids  are  the  teeth  which  should  be  extract- 
ed, but  if,  as  is  often  the  case,  the  first  permanent  molars 
are  so  much  decayed  as  to  render  their  preservation  imprac- 
ticable, or,  at  least,  doubtful,  these  teeth  should  be  remov- 
ed in  their  stead.  After  the  removal  of  the  second  bicus- 
pids, the  first,  usually,  very  soon  fall  back  into  the  places 


164  TREATMENT    OF   IRREGULAllITY  OF  THE   TEETH. 

wliicli  they  occupied,  and  furnish  ample  room  for  the  cus- 
pids and  incisors.  But  if  they  fail  to  do  this,  they  may  be 
gradually  forced  back  by  inserting  wedges  of  wood  or  gum 
elastic  between  them  and  the  cuspids,  or  by  means  of  a  lig- 
ature of  silk,  or  gum  elastic,  fastened  to  the  first  molar  on 
each  side,  and  securely  tied.  These  should  be  renewed 
every  day,  until  the  desired  result  is  produced. 

The  most  frequent  kind  of  irregularity,  resulting  from 
narrowness  of  the  jaw,  is  the  projection  of  the  cuspids. 
These  teeth^  with  the  exceiDtion  of  the  second  and  third  mo- 
lars, are  the  last  of  the  teeth  of  second  dentition  to  be  erupt- 
ed, and  are,  consequently,  more  liable  to  be  forced  out  of 
the  arch  than  any  others,  especially  when  it  is  so  much  con- 
tracted as  to  be  almost  entirely  filled  before  they  make  their 
appearance.  The  common  practice  in  such  cases  is  to  re- 
move the  projecting  teeth.  But  as  the  cuspids  contribute 
more  than  any  of  the  other  teeth,  except  the  incisors,  to  the 
beauty  of  the  mouth,  and  can,  in  almost  every  case,  be 
brought  to  their  proper  place,  the  practice  is  injudicious. 
Instead  of  removing  these,  a  bicuspis  should  be  extracted 
from  each  side.  When  the  space  between  the  lateral  in- 
cisor and  first  bicuspis  is  equal  to  one-half  the  width  of  the 
crown  of  the  cnspid,  the  second  bicuspis  should  be  removed, 
but  when  it  is  less,  the  first  should  be  taken  out,  for  the 
reason,  that,  although  the  crown  of  the  latter  may  be  car- 
ried far  enough  back  after  the  removal  of  the  former,  to  ad- 
mit the  crown  of  the  cusj^id  between  it  and  the  lateral  in- 
cisor, the  root  of  this  tooth  will  remain  in  front  and  part- 
ly across  the  root  of  the  first  bicuspis,  leaving  a  more  or 
less  prominent  vertical  ridge  on  the  anterior  part  of  the  al- 
veolar border,  which,  to  some  extent,  at  least,  acts  as  an  ir- 
ritant to  the  gums  and  periosteum. 

As  the  incisors  of  the  upper  jaw  are  more  conspicuous 
than  those  of  the  lower,  and  wlien  aygU  arranged  contribute 
more  to  the  beauty  of  the  mouth,  their  preservation  and 
regularity  are  of  greater  relative  importance.  Hence,  the 
removal  of  a  lateral  incisor,  when  it  is  situated  behind  the 


TREATMENT   OF   IRREGULARITY   OF    THE   TEETH. 


165 


circle  of  the  other  teeth,  as  is  often  done,  with  a  view  of 
remedying  the  deformity  produced  hy  false  position,  is  a 
practice  which  cannot  he  too  strongly  deprecated,  provided 
sufficient  space  can  he  made  for  it  between  the  cuspid  and 
central  incisor,  hy  the  removal  of  a  hicuspis  from  each  side 
side  of  the  jaw. 

But,  in  describing  the  treatment  of  irregularity,  we  will 
commence  witli  an  incisor  occupying  an  oblique  or  trans- 
verse position  across  the  alveolar  ridge,  so  that  the  cutting 
edge  of  the  tooth,  instead  of  being  in  a  line  with  the  arch, 
forms  an  angle  with  it  from  forty  to  ninety  degrees.  This 
variety  of  deviation  is  rarely  met  with  in  both  centrals,  but 
often  occurs  with  one.  Some  dentists  have  recommended  in 
cases  of  this  sort,  when  the  space  between  the  adjoining 
central  and  lateral  incisor  is  equal  to  the  width  of  the  devi- 
ating tooth,  to  turn  the  latter  in  its  socket  with  a  pair  of 
forceps,  or  to  extract  and  immediately  replace  it  with  the 
labial  face  of  the  organ  outwards.  It  is  scarcely  necessary 
to  sa}^,  that  if  a  tooth  is  extracted  or  turned  in  its  socket, 
the  vessels  and  nerves  from  which  it  derives  its  nourishment 
and  vitality  are  severed,  and  tliough  its  connection  witli  the 
alveolus  may  be  partially  re-established,  it  will  be  liable  to 
act  as  a  morbid  irritant. 

The  tooth,  however, 
may  be  brought  to  its 
proper  position  without 
incurring  the  risk  of  in- 
jury by  accurately  fit- 
ting a  gold  ring  or  band 
with  knobs  on  the  labial 
and  palatine  sides ;  to 
each  of  these,  a  ligature 
should  be  attached. — 
Thus  fastened  to  the 
ring,  each  end  should  be 
carried  back,  one  on  either  side,  in  front  and  behind  the 
arch,  and  secured  to  the  bicuspids  in  the  manner  as   rep- 


FiQ.  52. 


166     TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 

resented  in  Fig.  52,  to  act  constantly  upon  the  irregular 
tootli.  The  ligatures  should  be  renewed  from  day  to  day, 
until  the  tooth  assumes  its  proper  position. 

But  before  attemj^ting  to  turn  the  deviating  organ,  it 
should  be  ascertained  if  the  aperture  between  the  adjoining 
teeth  is  sufficient  to  admit  of  the  operation.  If  it  is  not,  it 
should  be  increased  by  the  extraction  of  a  bicuspis  fiom 
each  side  of  the  jaw,  and  moving  the  teeth  in  front  of  them 
backwards  until  sufficient  room  is  obtained.  The  time  re- 
quired to  do  this  will  vary  from  three  to  eight'or  ten  weeks, 
depending  upon  the  number  of  teeth  to  be  acted  on,  and  the 
age  of  the  patient. 

Narrowness  of  the  alveolar  border  is  sometimes  a  cause  of 
irregularity  of  the  upper  incisors.  In  this  case,  the  centrals^ 
usually  project,  though  it  sometimes  happens  that  some  are 
in  front  and  some  behind  the  arch,  producing  great  defor- 
mity ;  to  remedy  Avhich,  the  second  bicuspids  should  be  re- 
moved, unless  the  first  molars  are  so  much  affected  by  caries 
as  to  render  their  preservation  doubtful.  In  this  case,  they 
should  be  extracted,  in  place  of  the  second  bicuspids. 

The  following  case  will  serve  to  illustrate  the  means  em- 
ployed for  remedying  this  description  of  deformity.  The 
subject  was  a  young  lady  fifteen  years  of  age.  Her  teeth 
presented  the  arrangement  as  seen  in  Fig.  53. 

Fig.  53.  The  sccond  molars  of  the  upper 

jaw  occuijied  their  pi'oper  position 
in  the  alveolar  arch,  or  in  other 
words,  they  were  a  little  more  than 
an  inch  and  a  quarter  apart ;  the 
first  molars  were  hardly  an  inch 
apart,  and  the  first  bicuspids  were 
^  i^t,  I  still  nearer    to   each  other.      The 
*^lJ  cuspids,  except  having  been  push- 
- .  ^-  ^  J  ed  a  little  too  far  forward,  occu- 

""^^  pied,  very  nearly,  their  proper  po- 

sition. The  right  central  and  left  lateral  incisors  projected 
fully  a  quarter  of  an  inch,  lifting  and  otherwise  annoying 


TREATMENT   OF   IRREGULARITY    OF    THE   TEETH. 


16Y 


and  disfiguring  the  upper  lip  :  the  left  central  was  thrown 
back  and  partly  between  the  right  central  and  left  lateral, 
while  the  right  lateral  occii2)ied  a  position  in  a  line  with  it. 


Without  going  into  a  minute  de- 


FiG.  54. 


tail  of  the  method  adopted  for  pro- 
curing the  appliance  employed,  it 
will  be  sufficient  to  refer  the  reader 
to  Fig.  54.  This  represents  a  plas- 
ter model  of  the  teeth,  alveolar 
border_,  palatine  arch,  and  the  ap- 
paratus employed  for  remedying 
the  deformity.  The  second  bicus- 
pids were  first  extracted,  then,  by 
means  of  ligatures  applied  to  the 
second  molars  and  first  bicuspids,  and  made  fast  to  a  band 
of  gold  passing  on  the  outside  of  the  arch,  which  were 
renewed  every  day,  these  teeth  were  brought  out  to  their 
proper  position  in  eleven  weeks  ;  this  done,  there  was  a 
space  of  nearly  an  eighth  of  an  inch  between  the  cuspids 
and  first  bicuspids  ;  this  was  filled  up,  by  bringing  back 
Avith  ligatures,  the  former  to  the  latter.  A  ligature  was 
next  applied  to  the  right  lateral,  passed  through  a  hole  in 
the  gold  band  in  front,  and  made  fast.  In  ten  days  this 
tooth  was  brought  to  its  proper  place.  A  ligature  was  now 
attached  to  a  knob  soldered  on  the  gold  plate  behind  the 
teeth  on  the  inner  side  of  the  alveolar  border  for  the  pur- 
pose, and  tied  tiglitly  in  front  of  the  projecting  right  cen- 
tral incisor.  In  about  three  weeks 
this  was  brought  to  a  position  along 
side  the  lateral  incisor  of  the  same 
side.  The  left  central  was  then,  in 
like  manner,  brought  forward,  and 
the  left  lateral  carried  backward  to 
its  proper  place. 

After  the  deformity  was  corrected, 
the  teeth  presented  the  arrangement 
represented  in  Fig.  55,  taken  from 


Fig.  55. 


168  TREATMENT   OF   IRREGULARITY    OF   THE   TEETH, 

a  plaster  model  of  the  upper  jaw.  To  correct  the  irregu- 
larity in  this  case,  required,  in  all,  twenty-one  weeks.  If 
all  the  teeth  could  have  been  acted  upon  at  the  same  time, 
the  operation  might  have  been  accomplished  in  a  shorter 
period.  It  was  found  necessary,  too,  in  consequence  of  the 
diseased  action  occasioned  by  the  apparatus,  in  the  gums, 
to  remove  it  every  eight  or  ten  days,  and  let  it  remain  off 
each  time  twenty-four  hours.  It  may  be  proper  also,  to  ob- 
serve, that  every  time  the  ligatures  were  removed,  it  was 
taken  from  the  mouth,  and  the  teeth  thoroughly  cleansed. 

For  moving  a  projecting  incisor  or  cuspidatus  backwards, 
a  gold  spiral  spring  was  formerly  employed.  It  was  found 
to  be  more  efficient  than  a  ligature  of  silk,  inasmuch  as  it 
kept  up  a  constant  traction  upon  the  deviating  tooth.  But 
it  is  objectionable  on  account  of  the  annoyance  it  causes  the 
patient.  A  ligature  of  gum  elastic  is  far  preferable,  and 
this  material  is  now  very  generally  employed  in  the  treat- 
ment of  every  description  of  irregularity  in  which  agencies 
of  this  sort  are  required. 

There  are  otlier  varieties  of  irregularity  of  the  upper  in- 
cisors, but  we  shall  only  notice  one,  wliich,  from  its  pecu- 
liar character,  is  sometimes  exceedingly  difficult  to  remedy. 
It  is,  when  one  or  more  of  these  teeth  are  placed  so  far  back 
in  the  jaw,  that  the  under  teeth  come  before  it  or  them  at 
each  occlusion  of  the  mouth. 

Fig.  66. 

Of  this  variety,  Mr,  Fox  enu- 
merates four  kinds  : — The  first 
is,  when  one  of  the  central  in- 
cisors is  situated  so  far  back, 
that  the  lower  teeth  shut  over 
it,  while  the  other  central  re- 
mains ill  iLs  proper  place,  as  represented  in  Fig.  56,  copied 
from  his  work,  as  are  also  those  which  follow. 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH. 


169 


The  second  is,  when  both  of 
the  centrals  have  come  out  be- 
hind the  circle  of  the  other 
teeth,  and  the  lateral  occupy 
their  own  proper  position,  as 
represented  in  Fig.  57. 


Fig.  57. 


The  third  is,  when  the  lat- 
eral incisors  are  thrown  so  far 
back,  that  the  under  teeth  shut 
before  them,  while  the  centrals 
are  well  arranged,  as  exhibited 
in  Fig;.  58. 


Fig.  58. 


Fig.  59. 


The  fourth  kind  is,  when  all 
the  incisors  are  placed  so  far 
behind  the  arch  that  the  lower 
teeth  shut  before  them,  as  in 
Fig.  59. 


He  might  also  have  added  to  this  variety  a  fifth  descrip- 
tion, for  it  sometimes  happens  that  the  cuspids  of  the  up- 
per jaw  are  thrown  so  far  back,  as  to  fall  on  the  inside  of 
the  lower  teeth.  The  author  has  met  with  several  cases  of 
this  description  of  deviation. 

Two  things  are  necessary  in  the  treatment  of  the  kinds  of 
irregularity  just  described;  the  first  is,  to  prevent  the  upper 
and  lower  teeth  from  coming  entirely  together,  by  placing 
between  them  some  hard  substance,  so  that  the  former  may 
not  be  prevented  by  the  latter  from  being  brought  forward. 
The  second  is,  the  application  of  some  fixture  that  will  ex- 
ert a  constant  and  steady  pressure  upon  the  deviating  teeth, 
until  they  pass  those  of  the  lower  jaw. 

For  the  accomi)li.shment  of  this^  various  plans  have  been 
proposed.  Duval  recommends  the  application  of  a  grooved 
or  guttered  plate,  and  Catalan  has  invented  an  instrument, 
12 


170 


TREATJEENT   OF   IRREGULARITY   OF   THE  TEETH. 


Fig.  60 


based,  we  believe,  upon  the  same  principle,  but  much  bet- 
ter adapted  to  the  purpose.  We  doubted  tbe  efficiency  of 
the  inclined  plane  of  Catalan,  until  we  bad  employed  it, 
and  found  it  an  effectual  and  speedy  method  of  moving  de- 
viating front  teeth  in  the  upper  jaw,  from  behind  the  den- 
tal circle  to  their  proper  places.  It  acts  with  great  force, 
and  in  precisely  the  proper  manner  for  the  accomplishment 
of  the  object. 

The  accompanying  cuts, 
copied  from  Catalan,  ex- 
hibit the  manner  in  which 
his  inclined  plane  is  con- 
structed. The  one  here 
represented,  is  applied  to 
a  case  where  all  the  upper 
incisors  fall  behind  the 
lower  front  teeth .  Its  con- 
struction should  be  varied 
to  suit  the  peculiarity  of 
each  case .  If  but  one  tooth 
deviates^  only  one  inclined 
plane  will  be  required. 
The  apparatus  should  also 
be  so  adapted  and  secured 
to  the  teeth  as  to  occasion 
as  little  inconvenience  to 
the  patient  as  possible.  The  circular  bar  or  plate  of  gold^ 
running  round  in  front  of  the  teeth,  should  reach  from  the 
first  molar  on  one  side  to  the  first  molar  on  the  other, 
and  the  plate,  extending  up  from  it  should  cover  the  grind- 
ing surfaces  of  these  teeth,  and  be  long  enough  to  cover 
their  lingual  faces  also^  as  the  whole  fixture  will  thereby  be 
rendered  firmer  and  more  secure. 

In  the  application  of  this  principle  for  the  correction  of 
irregularitiy,  the  author  has  been  in  the  habit  of  construct- 
ing the  apparatus  somewhat  differently.  With  a  brass 
model  and  zinc  counter-model,  he  has  a  plate  of  gold  struck 


TREATMENT   OF   IRREGULARITY   OF   THE   TEETH. 


171 


up  over  all  the  teetli,  when  practicablej  as  far  back  as  the 
first  or  second  molar^  completely  incasing  them  and  the  al- 
veolar ridge  in  it.  An  encasement  of  this  sort,  possesses 
greater  stability  than  can  be  obtained  for  an  appliance  like 
the  one  represented  in  Figs.  60  and  61. 

Fi8.  62.  Fio.  63. 

1 


In  Fig.  62,  is  seen 
a  rei:)resentation  of  an 
inclined  plane  for 
bringing  forward  a 
central  incisor  which 
had  come  out  about 
a  quarter  of  an  inc'i! 
behind  the  circle  of 
the  other  teeth.  The 
manner  of  the  action 
of  this  instrument 
upon  the  deviating 
tooth  is  shown  in 
Fig.  63. 

The  plan  proposed  by  Delabarre,  is  to  pass  silk  ligatures 
round  the  teeth,  in  such  a  way  that  a  properly  directed  and 
steady  pressure  will  be  exerted  on  such  of  the  teeth  as  are 
situated  behind  the  arch,  and  to  keep  the  jaws  from  coming 
in  contact,  he  recommends  the  application  of  a  metallic 
grate,  fitted  to  two  of  the  inferior  molars,  (see  Fig.  64,) 
taken  from  his  treatise  on  second  dentition,  a  Represents 
a  ligature  round  the  teeth,  and  h  a  metallic  grate  on  two  of 
the  lower  teeth. 

This  plan  possesses  the  merit  of  simplicity,  and  occasions 


172 


TREATMENT   OF   IRREGULARITY   OF   THE   TEETH, 


but  little  or  no  inconvenience  to  the  patient ;  but  it  will 
sometimes  be  found  not  only  inefficient,  but  also  to  loosen 
the  teeth  adjacent  to  those  to  be  brought  forward.  The 
force  on  the  irregular  teeth,  and  those  against  which  the 
ligatures  act,  being  equal,  and  in  opposite  directions,  the 
latter  will  be  drawn  back,  while  the  former  are  brought  for- 
ward ;  and  thus  the  means  used  for  the  correction  of  one 
evil,  will  sometimes  occasion  another.  The  author  has  used 
it,  however,  in  some  cases,  with  the  most  satisfactory 
results. 

Fig.  65.  ^        ipj^g    meaus     recommended 

by  Mr.  Fox,  consists  of  a  gold 
bar  about  the  sixteenth  part 
of  an  inch  in  width^  and  of 
proportionate  thickness,  bent 
to  suit  the  curvature  of  the 
mouth,  and  fastened  with  lig- 
atures to  the  temporary  molars  of  each  side.  It  is  pierced 
opposite  to  each  irregular  tooth  with  two  holes.  The  teeth 
of  the  upper  and  lower  jaw  are  prevented  from  coming  en- 
tirely together  by  means  of  thin  blocks  of  ivory,  attached 
to  each  end  of  the  bar  by  small  pieces  of  gold,  and  resting 
upon  the  grinding  surfaces  of  the  temporary  molars.  (See 
Pig.  65.) 

^'<'-  ^^'  After    the  instrument 

has   been   thus    fastened 
to  the   teeth,    silk   liga- 
tures   are   passed   round 
such  as  have  deviated  to 
the  interior_,  and  through 
the  holes  opposite  them, 
and  then  tied  in  a  firm 
knot_,   on  the  outside   of 
the  bar.     (See  Fig.  66.) 
The  ligatures  must  be  renewed  every  three  or  four  days, 
until  the  teeth  shall  have  come  forward  far  enough  to  fall 
plumb  on  those  that  formerly  shut  before  them  and  acquired 


TREATMENT  OF  IRREGULARITY  OF  THE  TEETH.      173 

a  sufficient  degree  of  firmness  to  prevent  them  from  return- 
ing to  their  former  position.  But  as  soon  as  the  teeth  shut 
perpendicularly  upon  each  Other,  the  hlocks  may  he  re- 
moved, and  the  bar  alone  retained. 

Since  1830,  many  practitioners,  both  in  England  and  the 
United  States  have  substituted  caps  of  gold  for  the  blocks  of 
ivory  recommended  by  Mr.  Fox  ;  and  instead  of  simply 
bending  the  bar,  they  now  swage  it  between  a  metallic  east 
and  die,  so  that  all  its  parts,  except  those  immediately  op- 
posite the  irregular  teeth,  may  be  perfectly  adapted  to  the 
dental  circle.  The  apparatus,  with  these  modifications,  is 
more  comfortable,  and  less  liable  to  move  uj)on  the  teeth. 

Mr.  Fox  directs,  that  the  blocks  of  ivory  should  be  placed 
upon  the  temporary  molars,  but  the  caps  of  gold  now  sub- 
stituted are  entirely  disconnected  from  the  bar,  and  are  often 
used  after  the  moulting  of  these  teeth ;  they  are  then  placed 
upon  the  first  permanent  molars. 

As  the  caps  prevent  the  teeth  from  coming  together, 
mastication,  during  the  time  they  are  worn,  is,  necessarily, 
performed  on  them.  They  should,  therefore,  be  placed 
upon  the  largest  and  strongest  teeth  ;  and  for  this  reason 
they  should  be  applied  to  the  molars. 

The  curved  bar  should  be  washed  and  the  teeth  cleansed 
every  time  the  ligatures  are  renewed.  If  this  be  neglected, 
the  particles  of  food  that  collect  between  it  and  the  teeth, 
will  soon  become  putrid  and  offensive,  constituting  a  source 
of  disease  both  to  the  gums  and  teeth. 

But  before  the  bar  is  applied,  it  should  be  ascertained 
whether  there  is  sufficient  space  for  the  deviating  teeth, 
and  if  there  is  not,  room  should  be  made  in  the  manner  as 
before  described. 

Some  diversity  of  opinion  exists  as  to  the  most  suitable 
age  for  the  correction  of  this  description  of  irregularity. 
Mr.  Fox,  it  would  seem,  preferred  the  period  immediately 
previous  to  the  moulting  of  the  temporary  molars — probably 
the  tenth  or  eleventh  year  after  birth. 

Some  think,  that  the  forepart  of  the  dental  arch  con- 


1*74  TREATMENT   OF   IRREaULARITY   OF   THE  TEETH. 

tinues  to  expand  until  the  second  denture  is  completed,  and 
that  the  bicuspids  afford  a  better  support  for  the  ends  of  the 
bar  than  any  other  teeth,  and  are  content  to  wait  until  the 
fifteenth  or  even  sixteenth  year.  But,  though  the  arch  does 
sometimes  expand  a  little,  yet  even  when  the  exj^ansion 
occurs,  it  is  generally  so  inconsiderable,  that  little  advan- 
tage can  be  derived  from  it.  Moreover,  the  arch,  instead  of 
expanding,  is  much  more  liable  to  contract  whenever  a 
vacancy  occurs  in  the  dental  circle,  either  by  the  extraction 
or  from  the  improper  growth  of  one  or  more  of  the  teeth ; 
hence^  the  difficulty  is  apt  to  be  increased  by  delay. 

The  evil,  it  is  true,  may  be  remedied  at  the  fifteenth, 
seventeenth,  or  even  eighteenth  year ;  but  it  is  rarely 
advisable  to  defer  it  to  so  late  a  period. 

The  most  that  is  required  in  the  treatment  of  irregu- 
larity of  the  lower  incisors,  is  to  remove  a  tooth_,  and  to 
apply  frequent  jjressure  to  the  deviating  organs.  The 
lower  incisors  are  less  conspicuous  than  those  of  the  upper 
jaw,  and  the  loss  of  one,  if  the  others  are  well  arranged,  is 
scarcely  perceptible. 


CHAPTER     THIRTEENTH. 

DEFORMITY   FROM   EXCESSIVE  DEVELOPMENT  OF    THE 
TEETH  AND  ALVEOLAR  RIDGE  OF  LOWER  JAW. 


^'°-  ^'^-  When  the  teeth  of  the  lower 

jaw  form  a  larger  arch  than 
those  of  the  upper,  the  incisors 
and  cuspids  of  the  former  shut 
in  front  of  those  of  the  latter, 
causing  the  chin  to  project, 
and  otherwise  impairing  the 
symmetry  of  the  face.  This 
description  of  deformity  may  result  from  two  causes,  namely, 
excessive  development  of  the  teeth  and  alveolar  arch,  and 
partial  luxation  and  protrusion  of  the  lower  jaw.  But  we 
shall  confine  our  remarks  in  this  chapter  to  the  treatment 
of  that  produced  by  the  former. 

TREATMENT. 

The  remedial  indications  of  the  deformity  in  question, 
consists  in  diminishing  the  size  of  the  dental  arch,  which  is 
always  a  tedious  and  difficult  operation,  requiring  a  vast 
amount  of  patience  and  perseverance  on  the  part  of  the 
patient^  and  much  mechanical  ingenuity  and  skill  on  the 
part  of  the  dentist.  The  appliances  to  he  employed  have^ 
of  necessity,  to  be  more  or  less  complicated,  requiring  the 
most  perfect  accuracy  of  adaptation  and  neatness  of  execu- 
tion ;  they  must  also  be  worn  for  a  long  time,  and,  as  a 
natural  consequence,  are  a  source  of  considerable  annoyance. 

In  the  treatment  of  a  case  of  this  sort,  the  first  thing  to 


1*1  Q  PROTRUSION   OF   LOWER   FRONT  TEETH. 

be  done,  is,  to  extract  the  first  Licuspid  on  eacli  side  of  tlie 
jaw.  Sufficient  room  will  be  thus  obtained  for  the  contrac- 
tion, which  it  will  be  necessary  to  efiect  in  the  dental  arch, 
for  the  accomplishment  of  the  object.  An  accurate  impres- 
sion of  the  teeth  and  alveolar  ridge,  should  be  taken,  in  the 
manner  to  be  hereafter  described,  with  wax,  previously 
softened  in  warm  water.  From  this  impression,  a  plaster 
model  is  procured,  and  afterwards,  a  metallic  model  and 

counter-model . 

^lo-  68.  This  done,  a  gold  plate 

of  the  ordinary  thickness 
should  be  swaged  to  fit 
the  first  and  second  mo- 
lars, if  the  second  has 
made  its  appearance,  and 
if  not,  the  second  bicus- 
pid and  first  molar  on 
each  side  of  the  jaw,  so 
as  completely  to  incase 
these  teeth.  If  these  caps  are  not  thick  enough  to  pre- 
vent the  front  teeth  from  coming  together,  a  piece  of  gold 
plate  may  be  soldered  on  that  part  of  each  which  covers  the 
grinding  surfaces  of  the  teeth,  and  having  proceeded  thus 
far,  a  small  gold  knob  is  soldered  on  each  side  of  each  cap, 
and  to  each  of  which  a  ligature  of  silk  or  gum  elastic  is 
attached.  These  ligatures  are  now  brought  forward  and 
tied  tightly  around  the  cuspids.  When  thus  adjusted,  the 
lower  arch  will  present  the  appearance  exhibited  in  Fig.  68. 
By  this  means  the  cuspids  may^  in  fifteen  or  twenty  days, 
be  taken  back  to  the  bicuspids ;  but,  if  in  their  progress 
they  are  not  carried  towards  the  inner  part  of  the  alveolar 
ridge,  the  outer  ligatures  may  be  left  off  after  a  few  days, 
and  the  inner  ones  only  employed,  to  complete  the  re- 
mainder of  the  operation. 

After  the  positions  of  the  cuspids  have  been  thus  changed, 
the  gold  caps  should  be  removed  and  a  circular  bar  of  gold, 
extending  from  one  to  the  other,  so  constructed  as  to  pass 


PROTRUSION   OF   LOWER  FRONT  TEETH. 


m 


about  a  quarter  of  an  inch  behind  the  incisors,  should  now 
be  soklered  at  each  end  to  the  inner  side  of  each  cap,  and  a 
hole  made  through  it  behind  each  of  the  incisors,  through 
which  a  ligature  of  silk  may  be  passed,  and  after  it  is  placed 
in  the  mouth,  it  is  brought  forward  and  tied  tightly  in  front 
of  each  tooth.  These  ligatures  should  be  renewed  every 
day  until  the  teeth  are  carried  far  enough  back  to  strike  on 
the  inside  of  the  corresponding  teeth  in  the  upper  jaw. 

Fig.    69   represents   the  Fig.  69. 

appearance  which  a  plaster 
model  of  the  lower  jaw  pre- 
sents with  the  last  named 
apparatus  on  it,  and  an  ex- 
amination of  this  will  con- 
vey a  more  correct  idea  of 
its  construction,  and  the 
manner  of  its  application, 
and  mode  of  action  than 
any    descrii^tion    which   can   be   given. 

An  appliance  of  this  sort  may  be  made  to  act  with  great 
eificiency  in  remedying  the  deformity  in  question,  but,  in 
its  application,  it  is  necessary  that  the  caps  be  fitted  with 
the  greatest  accuracy  to  the  teeth,  and  they  should  be  re- 
moved every  day  and  thoroughly  cleansed,  as  well  as  the 
teeth  they  cover.  If  this  precaution  is  neglected,  the  secre- 
tions of  the  mouth,  which  collect  between  the  gold  caps  and 
teeth,  will  soon  become  acrid  and  corrode  the  latter.  It 
should  always,  therefore,  be  strictly  observed. 


CHAPTER    FOURTEENTH. 

PROTRUSION  OF  THE  LOWER  JAW. 

Tms  deformity,  altliougli  produced  by  a  different  cause 
from  the  one  last  described,  is  precisely  similar  to  it,  and 
gives  to  the  lower  part  of  the  face  an  exceedingly  morose 
and  disagreeable  appearance.  It  also  interferes  with  masti- 
cation, and  often  with  prehension  and  distinct  utterance. 
It  wholly  changes  the  relationship  which  the  teeth  should 
sustain  to  each  other  when  the  mouth  is  closed.  The  cusps 
or  protuberances  of  the  bicuspids  and  molars  of  one  jaw, 
instead  of  fitting  into  the  depressions  of  the  corresponding 
teeth  of  the  other,  often  strike  their  most  prominent  points ; 
at  other  times  the  outer  protuberances  of  the  lower  molars 
and  bicuspids,  instead  of  fitting  into  the  depressions  of  the 
same  class  of  teeth  in  the  upper  jaw,  shut  on  the  outside  of 
these  teetli.  The  trituration  of  aliments  is  consequently 
rendered  more  or  less  imperfect. 

The  description  of  deformity  under  consideration  is  char- 
acterized by  the  protrusion  of  the  lower  jaw,  and  is  supposed 
to  be  the  result  of  a  "natural  partial  luxation."  It  is  of 
more  frequent  occurrence  than  the  one  which  results  from 
excessive  development  of  the  teeth  and  alveolar  ridge,  and 
requires,  as  before  stated,  an  entirely  different  plan  of  treat- 
ment. It  rarely  occurs  previously  to  second  dentition,  but 
is  occasionally  met  with  previously  to  that  period. 

TREATMENT. 

The  plan  of  treatment  usually  adopted,  consists  in  fasten- 
ing a  small  block  of  ivory  on  one  of  the  lower  molars,  thick 


PROTRUSION   OF   LOWER   JAW. 


179 


enough,  to  keep  the  front  teeth  about  a  quarter  of  an  inch 
apart  when  the  jaws  are  closed.  Fox's  bandage  is  now  ap- 
plied. This  is  buckled  as  tightly  as  the  patient  can  bear 
with  convenience,  pressing  the  chin  upwards  and  back- 
wards. A  piece  of  tough  wood,  slightly  hollowed  so  as  to 
fit  the  arch  of  the  lower  teeth,  made  narrow  at  the  upper 
end,  is  introduced  between  the  teeth  several  times  a  day, 
the  concave  j)ortion  resting  upon  the  outside  of  the  lower, 
and  against  the  inside  of  the  upper,  employing  at  each  time 
as  much  pressure  as  can  be  safely  applied.  By  continuing 
this  operation  from  day  to  day,  for  several  weeks,  the  natu- 
ral relationship  of  the  jaws  will,  in  most  cases,  be  restored.* 


The   description  of  bandage  ^^*^-  '^^' 

here  alluded  to,  and  the  man- 
ner of  its  application  is  repre- 
sented in  Fig.  70.  When  the 
protrusion  of  the  lower  jaw  is 
accompanied  by  irregularity, 
means  should,  at  the  same  time, 
be  employed  for  remedying  it. 
The  earlier  the  treatment  is  in- 
stituted, the  more  easily  will 
the  deformity  be  overcome.  It 
may,  however,  be  successfully 
remedied  at  any  time  previously 
to  the  twentieth  year  of  age,  and  sometimes  at  a  much 
later  period,  but  that  after  this  time  the  operation  becomes 
more  difficult. 


In  cases  where  the  lower  front  teeth  shut  over  the  upper, 
and  thus  cause  a  deformity  of  the  face,  it  is  important  to 
discriminate  correctly  between  those  which  result  from  mal- 
formation, and  a  protrusion  of  the  jaw  occasioned  by  partial 


*  An  interesting  article  by  Dr.  J.  S.  Gunnell,  on  the  treatment  of  deformities  of 
this  kind,  is  contained  in  one  of  the  early  volumes  of  the  American  Journal  of 
Dental  Science. 


180  PROTRUSION   OF   LOWER   JAW. 

luxation,  as  the  remedial  indications  in  th.e  two  are  entirely 
diflfcrent.  Those  which  would  prove  successful  in  the  one, 
would  prove  unsuccessful  in  the  other.  But,  fortunately, 
deformity  arising  from  the  last  mentioned  cause,  is,  compar- 
atively, of  rare  occurrence  ;  hence  the  dentist  is  seldom 
called  upon  to  exercise  his  ingenuity  and  skill  in  its  treat- 
ment. 


CHAPTER    FIFTEENTH. 

PECULIARITIES  IN  THE  FORMATION  AND  GROWTH  OF 
THE  TEETH. 

In  the  development  and  growth  of  the  various  parts  of 
the  bodv,  curious  and  interesting  anomalies  are  sometimes 
observed,  but  in  no  portion  of  it  are  they  more  frequent 
in  their  occurrence  or  diversified  in  their  character  than  in 
the  teeth.  But  aberrations  in  the  formation  and  growth  of 
these  organs,  are,  for  the  most  part,  confined  to  the  teeth  of 
second  dentition. 

Mr.  Fox  gives  a  drawing  of  a  tooth  very  nearly  resem- 
bling the  letter  S.  The  malformation  was  caused  by  an 
obstructing  temporary  tooth.  The  author  has  also  met 
with  several  examples  of  teeth  similarly  deformed,  and  from 
like  causes. 

The  molars  of  the  upper  jaw  sometimes  have  four  and 
even  five  roots,  and  those  of  the  lower,  three  and  occasion- 
ally four.  The  crowns  of  the  teeth,  also,  frequently  pre- 
sent deviations  from  the  natural  shape  equall}'  striking  and 
remarkable. 

The  next  peculiarity  to  be  noticed,  is  that  of  size,  and  in 
this  respect  the  teeth  are  very  variable.  Even  in  tlie  same 
mouth,  the  want  of  relative  proportion  between  the  differ- 
ent classes  of  teeth,  is  sometimes  quite  conspicuous.  But 
examples  of  this  kind  are  not  very  frequent,  for  where  there 
is  an  increase  or  diminution  in  the  size  of  the  teeth  of  one 
class,  there  is  generally  a  corresponding  increase  in  those  of 
the  other. 

Aberrations  of  this  character  are  probably  dependent  upon 
some  diathesis  of  the  general  system,   whereby   the   teeth, 


182  PECULIARITIES   OF   THE   TEETH. 

during  the  earlier  stages  of  their   formation,  are  supplied 
with  an  excessive  or  diminished  (|uantitj  or  nutriment. 

Some  very  remarkable  deviations  have  heen  known  to 
take  place  in  the  growth  of  the  teeth.  The  most  singular 
case  on  record^  is  that  narrated  by  Albinus  :  "Two  teeth," 
says  he,  "between  the  nose  and  the  orbits  of  the  eye,  one  on 
the  right  side  and  the  other  on  the  left,  were  enclosed  in 
the  roots  of  those  processes  that  extend  from  the  maxillary 
bones  to  the  eminences  of  the  nose.  They  were  large,  re- 
markably thick,  and  so  very  like  the  canini,  that  they 
might  have  seemed  to  be  these  teeth  themselves,  which  had 
not  before  appeared  ;  but  the  canines  themselves  were  also 
present,  more  than  usuallj^  small  and  short,  and  placed  in 
their  proper  sockets.  The  former,  therefore,  appear  to  have 
been  the  new  canini,  which  had  not  penetrated  their  sock- 
ets, because  they  were  situated  where  these  same  teeth  are 
usually  observed  to  be  in  children.  But  what  is  still  more 
remarkable,  their  points  were  directed  towards  the  eyes,  as 
if  they  were  the  new  eye  teeth  inverted.  And  they  were 
also  so  formed,  that  they  were,  contrary  to  what  usually 
happens,  convex  on  the  posterior,  and  concave  on  the  ante- 
rior."* A  case  of  a  somewhat  similar  character  is  mention- 
ed by  Mr.  John  Hunter. 

The  following  case  is  in  the  words  of  Mr.  Gr.  Wait :  "While 
I  was  prosecuting  my  anatomical  studies,  I  was  struck  with 
the  appearance  of  a  cuspidatus  of  the  upper  jaw  ;  it  was 
short  and  appeared  as  if  the  body  of  the  tooth  was  in  the 
jaw,  and  tliat  it  was  the  tip  of  the  root  that  presented  itself. 
Upon   further    examination,    I    found   this    verified  ;    and 

*"Dente3  duo  inter  nasum  et  orbes  oculorum,  dexter  sinisterque,  inclusi  in  rad- 
icibus  proccssum  quibus  ossa  maxilarllaria  ad  eminentem  nasum  pertinent.  Longi 
sunt,  crassitudinis  insignis.  Similes  maximi  caninis,  ut  videri  possint  illi  ipsi  esse, 
non  nati.  At  aderant  praeterea  canini  prajter  consuetudinem  parvi,  et  brevis,  suis 
infixi  alveolis.  Itaque  videantur  esse  canini  novi,  qui  non  eruperint  uptote  ibi  loci 
collocati,  ubi  sunt  novi  illi  in  infantibus.  Sed  quod  miremur  sursum  directi,  tan- 
quam  si  sint  canini  novi  inversi.  Et  it  quoque  formati  sunt  ut,  contra  quamalii,  a 
posteriore  parte  gibbi,  ab  anteriore  sinuati  sint,"  &c. — Academ.  ^iias^at.  liber  1, 
p.  54. 


PECULIARITIES  OE  THE  TEETH.  183 

after  tlie  cranium  and  loM^er  jaw  were  properly  macerated 
and  cleansed,  I  found  one  of  the  lower  bicuspids  in  the  same 
manner." 

The  author  can  readily  imagine  that  a  cuspidatus  of  the 
upper  jaw  might,  while  in  a  rudimentary  state,  by  some 
false  or  unnatural  attachment  of  the  dental  sac^  be  so  alter- 
ed in  its  position,  as  to  pass  up,  in  its  growth,  between  the 
nose  and  orbit.  But  that  the  crown,  after  having  been  thus 
turned  round  in  the  socket,  should  remain  stationary,  while 
the  fang  jjassed  down  and  appeared  outside  of  the  gum,  is 
a  most  extraordinary  and  remarkable  anomalism.  In  the 
former  instance,  the  tooth  might  still  continue  to  derive  the 
nutriment  necessar}^  for  its  vitality  from  the  dental  vessels  ; 
but  in  the  latter  case,  it  could  not,  because  the  apex  of  the 
root,  the  place  where  the  vessels  and  nerves  enter,  were  en- 
tirely outside  of  the  gum.  He  cannot,  therefore,  but  think 
that  the  crown,  divested  of  enamel,  was  mistaken  for  the 
root. 

The  following  is  one  of  the  several  cases  of  deviation  in 
the  growth  of  the  teeth_,  that  have  come  under  the  author's 
observation.  In  1840,  he  was  requested  to  extract  a  tooth 
for  a  lady  of  Baltimore,  under  the  following  circumstances  : 
she  had,  for  a  time,  experienced  a  great  deal  of  pain  in  her 
upper  jaw,  and  supposed  it  to  originate  from  the  second 
molar  of  the  right  side,  but  which  was  perfectly  sound. 
Meanwhile  her  general  health  became  impaired,  and  her 
attending  pliysician,  thinking  that  the  local  irritation  might 
have  contributed  to  her  debility,  advised  her  to  have  the 
tooth  removed.  On  extracting  it,  the  cause  of  the  pain  at 
once  became  ajDparent.  The  dens  sapientiaa,  which  had  not 
hitherto  appeared,  was  discovered  with  its  fangs  extending 
back  to  the  utmost  verge  of  the  angle  of  the  jaw ;  while  its 
grinding  surface  had  been  in  contact  with  the  posterior  sur- 
face of  the  crown  and  neck  of  the  tooth  just  extracted.  On 
the  removal  of  the  wisdom  tooth,  the  j^ain  ceased. 

About  the  middle  of  December,  1849,  a  youth  aged  six- 
teen, applied  to  the  author  to  extract  a  right  superior  bicus- 


184  PECULIARITIES   OF   THE   TEETH. 

pid,  which,  he  said,  was  ulcerated  at  the  root.  On  examin- 
ing his  mouth,  he  discovered  hut  one  bicuspid,  hut  above 
and  between  the  root  of  this  and  that  of  the  first  molar,  he 
observed  a  small  fistulous  opening.  On  introducing  a  small 
probe,  it  immediately  came  in  contact  with  the  crown  of  a 
tooth  looking  towards  the  malar  process  of  the  superior 
maxillary,  which,  on  extraction,  proved  to  be  the  second 
bicuspid. 

The  author  has  in  his  possession  several  molar  and  bi- 
cuspid teeth,  which  have  small  nodes  upon  their  necks, 
covered  with  enamel ;  and  there  is  a  jaw  in  the  Museum 
of  the  Baltimore  Dental  College,  which  has  five  teeth  pre- 
senting this  anomaly. 

The  author  has  two  teeth  in  his  possession,  presented  to 
him  by  his  brother,  the  late  Dr.  John  Harris,  of  most  sin- 
gular shape.  They  were  extracted  in  July,  1822,  from  the 
right  side  of  the  upper  jaw  of  a  young  gentleman,  nineteen 
years  of  age,  by  the  name  of  Crawford.  They  occupied  the 
place  of  the  first  and  second  bicuspids,  and  their  crowns  are 
almost  wholly  imbedded  in  lamellated  dentine,  that  should 
have  constituted  their  roots,  but  which  are  entirely  wanting. 
Judging  from  their  appearance,  one  would  be  inclined  to 
sujjjDose,  that  their  sacs  failing  to  contract,  they  remained 
stationary  in  their  sockets,  and  as  the  base  of  the  pulps 
elongated,  they  came  in  contact  with  the  bottom  of  the 
alveoli  and  were  caused  to  bulge  out  and  to  be  reflected 
upon  their  crowns — to  the  enamel  of  which,  nearly  to  their 
grinding  surfaces,  they  are  perfectly  united.  For  some  time 
previously  to  the  extraction  of  these  teeth,  they  had  been 
productive  of  considerable  irritation  and  pain  in  the  gums 
and  jaw,  and  it  was  for  the  relief  of  this,  that  they  were  re- 
moved. 

Since  the  publication  of  the  second  edition  of  this  work, 
the  author  has  seen  a  still  more  remarkable  deviation  in 
the  growth  of  a  tooth.  It  is  in  the  upper  jaw  of  an  adult 
skull  in  the  Museum  of  the  Baltimore  Dental  College.  The 
natural  teeth  are  all  well  formed,  and  regularly  arranged 


PECULIARITIES   OF   THE  TEETH.  185 

in  the  alveolar  border,  but  between  tbe  extremities  of  the 
roots  of  the  superior  central  incisors,  in  the  substance  of  the 
}aWj  there  is  a  supernumerary  tooth,  the  crown  of  which 
looks  upwards  towards  the  crest  of  the  nasal  plates  of  the 
two  bones.  The  whole  tooth  is  about  one  inch  in  length, 
and  the  apex  of  the  crown  is  nearly  on  a  level  with  the  floor 
of  the  nasal  cavities.  There  is  also  in  the  museum  of  this 
institution  a  central  incisor  of  the  upper  jaw,  with  the  root 
bent  upon,  and  in  contact  with,  the  labial  surface  of  the 
crown.* 

*  This  tooth  was  presented  to  the  author,  by  Dr.  Williams,  dentist,  of  Alex- 
andria, Va. 


13 


CHAPTER    SIXTEENTH. 

OSSEOUS  WIOI  OF  THE  TEETH. 

Inclosed  as  each  tooth  is,  in  a  distinct  sac,  and  separated 
on  either  side  by  a  bony  partition,  from  the  adjoining  teeth, 
until  after  the  completion  of  the  formation  of  the  enamel,  it 
is  difficult  to  conceive  how  osseous  union  could  take  place 
between  two  of  these  organs,  and,  we  confess,  that  until  we 
actually  witnessed  an  example  of  it,  which  we  did  for  the 
first  time  in  1836,  we  were  inclined  to  doubt  the  possibility 
of  such  an  occurrence. 

During  a  visit  to  the  city  of  Richmond,  Va.,  in  April,  of 
the  above  mentioned  year,  we  had  an  opportunity  of  seeing 
two  cases.  One  consisted  in  the  union  of  the  crowns  of  the 
central  incisors  of  tlie  upj^er  jaw,  the  palatine  surface  of 
which  presented  the  appearance  of  one  broad  tooth,  while 
anteriorly,  they  had  the  semblance  of  two  teeth ;  the  other 
case,  consisted  in  the  union  of  the  right  central  and  lateral 
incisors  of  the  lower  jaw. 

A  professional  friend  of  Virginia,  informed  the  author,  in 
a  conversation  some  years  since,  that  he  had  met  with  a 
case  of  osseous  union  between  a  second  bicuspid  and  first 
molar  of  the  lower  jaw,  which  was  so  jialpable,  that  there 
could  have  been  no  doubt  of  its  existence. 

Mr.  Fox  has  given  the  drawings  of  four  cases,  the  origi- 
nals of  which,  as  Mr.  Bell  tells  us^  are  still  to  be  seen  in 
the  museum  of  Guy's  Hospital.  Mr.  B.  also  informs  us, 
that  he  has  seen  four  other  examples. 

Dr.  Koecker  is  sceptical  with  regard  to  the  existence  of 
osseous  union  of  the  teeth,  and  attributes  to  those  who 
assert  that  thev  have  met  with  cases  of  it.  "a  weak  credu- 


OSSEOUS  UNION   OF  THE  TEETH.  18*7 

lity — a  love  of  tlie  marvellous — or  a  desire  to  impose  upon 
the  world." 

Cases  of  this  sort,  it  is  true,  are  of  rare  occurrence,  and 
a  connection  of  the  fangs  of  two  teeth,  by  an  intervening 
portion  of  the  alveolus,  is  very  easily  mistaken  for  osseous 
union  of  the  roots  themselves.  A  few  years  since,  in  ex- 
tracting a  second  molar  of  the  upper  jaw,  the  author 
brought  the  dens  sapientiae  along  with  it.  At  first  he 
thought  there  was  osseous  union  of  the  roots,  but  upon  close 
examination,  found  a  very  thin  portion  of  the  alveolar 
wall  between,  to  which  their  roots  were  firmly  attached. 
Such  a  case  as  this,  would,  in  many  instances,  be  set  down 
as  an  example  of  osseous  union. 

It  is  easy  to  account  for  a  lusus  naturce  of  this  kind,  by 
supposing  a  previous  union  of  the  pulps  of  the  two  teeth. 
But  from  the  order  in  which  the  teeth  are  erupted,  some 
classes  appearing  long  before  others,  it  would,  on  this  sup- 
position, seem  that  it  could  only  occur  between  the  central 
incisors.  It  is  not,  however  thus  limited.  The  central  and 
lateral  incisors,  the  bicuspids,  and  the  molars,  are  sometimes 
united. 

An  osseous  union  of  the  teeth^  is,  fortunately,  of  rare  oc- 
currence ;  if  it  were  otherwise,  it  would  be  productive  of 
many  accidents  in  the  extraction  of  teeth.  Apart  from  this 
consideration,  it  can  be  of  but  little  importance,  either  to 
the  practitioner,  or  to  the  physiologist. 

Since  the  publication  of  the  first  edition  of  this  work,  sev- 
eral cases  of  osseous  union  of  the  teeth  have  fallen  under  the 
observation  of  the  author,  and  he  now  has  several  specimens 
in  his  anatomical  collection.  He  has  five  examples  of  osse- 
ous union  of  the  temporary  teeth.* 

The  author  has  more  recently  met  with  several  other  ex- 
amples of  osseous  union  of  temporary  teeth. 

*  For  the  specimens  above  alluded  to,  the  author  is  indebted  to  Dr.  Cassell,  Mr. 
Townsend  and  Dr.  Dwinelle. 


CHAPTER    SEVENTEENTH. 

SUPERNUMERARY  TEETH. 

The  development  of  supernumerary  teetli  is  usually  con- 
fined to  the  anterior  part  of  the  mouth,  and  more  frequently 
to  the  upper  than  to  the  lower  jaw.  They  sometimes,  how- 
ever, appear  as  far  back  as  the  dentes  sapientite,  and  Hud- 
son says,  he  has  seen  them  behind  these  teeth.  We  have 
now  in  our  anatomical  collection,  two  supernumerary  teeth 
that  were  extracted,  one  from  behind,  and  the  other  at  the 
side,  of  one  of  the  upper  wisdom  teeth.* 

The  crowns  of  supernumerary  teeth  which  appear  in  the 
anterior  part  of  the  mouth,  are  usually  of  a  conical  shape, 
and  for  the  most  part,  situated  between  the  central  in- 
cisors ;  they  usually  have  short,  knotty  roots  ;  sometimes, 
however,  they  bear  so  strong  a  resemblance  to  the  other 
teeth,  that  it  is  difficult  to  distinguish  the  one  from  the 
other.  We  once  saw  too  lateral  incisors  in  the  lower  jaw, 
both  of  which  were  so  well  arranged,  and  perfectly  formed, 
that  it  was  impossible  to  determine  which  of  the  two  ought 
to  be  considered  as  the  supernumerary.  Mr.  Bell  mentions 
a  case,  in  which  there  were  five  lower  incisors,  all  of  which 
were  well  formed  and  regularly  arranged.  The  author  has 
met  with  several  examples  in  which  supernumerary  teeth  in 
the  lower  jaw  so  closely  resembled  the  natural  incisors,  that 
no  difierence  could  be  discerned  between  them.  He  has  also 
seen  examples  of  three  lateral  incisors  in  the  upper  jaw, 
where  it  was  impossible  to  determine  which  was  the  super- 
numerary. 

*  These  teeth  were  removed  by  Dr.  Chewning,  dentist,  of  Fredericksburg,  Va. 


SUPERNUMERARY   TEETH.  189 

Supernumerary  cuspids  rarely  if  ever  occur,  but  supernu- 
merary bicuspids  are  occasionally  met  with.  Delabarre 
says,  he  has  seen  them  ;  and  we  have  met  with  three  exam- 
ples of  the  sort ;  in  each  of  these  instances  the  teeth  were 
very  small,  not  being  more  than  one-fourth  as  large  as  the 
natural  bicuspids^  with  oval  crowns,  and  placed  partly  on 
the  outside  of  the  circle,  and  partly  between  the  bicuspids. 
We  extracted  one  of  them,  and  have  it  still  in  our  posses- 
sion. Its  root  is  short,  round,  and  nearly  as  thick  at  its 
extremity  as  it  is  at  the  neck  of  the  tooth. 

The  supernumerary  teeth  that  appear  further  back  than 
the  bicuspids,  though  much  smaller,  bear  a  strong  resem- 
blance to  the  dentes  sapientise. 

Supernumerary  teeth,  although  generally  imperfect  in 
their  formation,  are  less  liable  than  other  teeth  to  decay. 
This  may  be  attributable  to  the  fact,  that  they  possess  a 
lower  degree  of  vitality,  are  harder,  and,  consequently,  not 
so  susceptible  to  the  action  of  the  causes  that  produce  the 
disease. 

Although  the  occurrence  of  supernumerary  teeth  rarely 
disturbs  the  arrangement  of  the  others^  their  presence  is 
sometimes  productive  of  the  worst  kind  of  irregularity ;  and 
even  when  they  do  not  have  this  effect,  they  impair  the 
beauty  of  the  mouth,  and,  for  this  reason^  should  be  extract- 
ed as  soon  as  their  crowns  have  completely  emerged  from 
the  gums. 

To  the  practitioner  of  dental  surgery,  the  occurrence  of 
supernumerary  teeth  is  interesting,  only  in  so  far  as  it  af- 
fects tlie  beauty  of  the  mouth  and  the  relationship  which 
the  teeth  of  the  upper  jaw  sustain  to  those  of  the  lower  ; 
but  to  the  physiologist,  it  involves  the  question,  what  de- 
termines their  development  ?  But  in  propounding  this 
interrogatory  it  is  not  our  intention  to  enter  upon  its  discus- 
sion in  this  place,  as  it  forms  no  part  of  the  design  of  the 
present  treatise. 


CHAPTER    EIGHTEENTH. 

THIRD   DENTITION. 

That  nature  sometimes  makes  an  effort  to  produce  a  third 
set  of  teeth,  is  a  fact  which^  however  much  it  may  be  dis- 
puted, is  now  so  well  established,  that  no  room  is  left  for 
cavil  or  doubt. 

The  following  interesting  particulars  are  taken  from 
Good's  Study  of  Medicine. 

"We  sometimes,  though  rarely,  meet  with  playful  at- 
tempts on  the  part  of  nature,  to  reproduce  teeth  at  a  very 
late  period  of  life,  and  after  the  permanent  teeth  have  been 
lost  by  accident,  or  by  natural  decay. 

"This  most  commonly  takes  place  between  the  sixty-third 
and  eighty-first  year,  or  the  interval  which  fills  up  the  two 
grand  climacteric  years  of  the  G-reek  physiologist ;  at  which 
period  the  constitution  appears  occasionally  to  make  an  ef- 
fort to  repair  other  defects  than  lost  teeth.        *       *       * 

"For  the  most  part,  the  teeth,  in  this  case,  shoot  forth  ir- 
regularly, few  in  number,  and  without  proper  fangs  ;  and, 
even  where  fangs  are  produced  without  a  renewal  of  sockets. 
Hence,  they  are  often  loose,  and  frequently  more  injurious 
than  useful,  by  interfering  with  the  uniform  line  of  indu- 
rated and  callous  gums,  which,  for  many  years  perhaps, 
had  been  employed  as  a  substitute  for  the  teeth.  A  case  of 
this  kind  is  related  by  Dr.  Bisset,  of  Knayton,  in  which  the 
patient,  a  female  in  her  ninety-eighth  year,  cut  twelve  mo- 
lar teeth,  mostly  in  the  lower  jaw,  four  of  which  were 
thrown  out  soon  afterwards,  while  the  rest,  at  the  time  of 
examination,  were  found  more  or  less  loose. 

"In  one  instance,  though  never  more  than  one,  Mr.  Hun- 


THIKD   DENTITION.  191 

ter  witnessed  the  reproduction  of  a  complete  set  in  botli 
jaws  apparently  with  a  renewal  of  their  sockets.  '^From 
which  circumstance,'  says  he,  ^and  another  that  sometimes 
happens  to  women  at  this  age,  it  would  appear  that  there  is 
some  effort  in  nature  to  renew  the  body  at  that  time.' 

''The  author  of  this  work  once  attended  a  lady  in  the 
country,  who  cut  several  straggling  teeth  at  the  age  of 
seventy-four  ;  and,  at  the  same  time,  recovered  such  an 
acuteness  of  vision,  as  to  throw  away  her  spectacles,  which 
she  had  made  use  of  for  more  than  twenty  years,  and  to  be 
able  to  read  with  ease  the  smallest  print  of  the  newspapers. 
In  another  case,  that  occurred  to  him_,  a  lady  of  seventy-six, 
mother  to  the  late  Henry  Hughes  Eryn,  printer  of  the  jour- 
nals of  the  House  of  Commons,  cut  two  molars,  and  at  the 
same  time  completely  recovered  her  hearing,  after  having 
for  some  years  been  so  deaf  as  to  be  obliged  to  feel  the  clap- 
per of  a  small  hand-bell,  which  was  always  kept  by  her,  in 
order  to  determine  whether  it  rung  or  not. 

"The  German  Ephemerides  contain  numerous  examples 
of  the  same  kind  ;  in  some  of  which,  teeth  were  produced 
at  the  advanced  age  of  ninety,  a  hundred,  and  even  a  hun- 
dred and  twenty  years.  One  of  the  most  singular  instances 
on  record,  is  that  given  by  Dr.  Slade,  which  occurred  to  his 
father  ;  who,  at  the  age  of  seventy-five,  reproduced  an  in- 
cisor^ lost  twenty-five  years  before^  so  that,  at  eighty,  he 
had  hereby  a  perfect  row  of  teeth  in  both  jaws.  At  eighty- 
two,  they  all  dropped  out  successively  ;  two  years  after- 
wards, they  were  all  successively  renewed,  so  that  at  eighty- 
five,  he  had  at  once  an  entire  set.  His  hair,  at  the  same 
time,  changed  from  a  white  to  a  dark  hue  ;  and  his  consti- 
tution seemed,  in  some  degree,  more  healthy  and  vigorous. 
He  died  suddenly,  at  the  age  of  ninety  or  a  hundred. 

"Sometimes  these  teeth  are  produced  with  wonderful  ra- 
pidity; but  in  such  cases,  with  very  great  pain,  from  the 
callosity  of  the  gums,  through  which  they  have  to  force 
themselves.  The  Edinburg  Medical  Commentaries  supply 
us  with  an  instance  of  this  kind.     The  individual  was  in 


192  THIRD   DENTITION. 

his  sixty-first  year,  and  altogether  toothless.  At  this  time, 
his  gums  and  jaw-bones  became  painful^  and  the  pain  was 
at  length  excruciating.  But,  within  the  space  of  twenty- 
one  days  from  its  commencement,  both  jaws  were  furnished 
with  a  new  set  of  teeth,  complete  in  number." 

A  late  physician  of  Baltimore  informed  the  author  in 
1838^  that  an  exami:)le  of  third  dentition  had  come  under 
his  own  observation.  The  subject  a  female,  at  the  age  of 
sixty,  he  assured  him,  erupted  an  entire  set  in  each  jaw. 

The  following  extract  of  a  letter  from  a  professional 
friend,*  describes  another  very  interesting  case. 

''I  have  just  seen  a  case  of  third  dentition.  The  subject 
of  this  'playful  freak  of  nature,'  as  Dr.  Grood  styles  it,  is  a 
gentleman  residing  in  the  neighborhood  of  Coleman's  Mill, 
Caroline  county,  Virginia.  He  is  now  in  his  seventy-eighth 
year,  and,  as  he  playfully  remarked,  'is  just  cutting  his 
teeth.'  There  are  eleven  out,  five  in  the  upper,  and  six  in 
the  lower  jaw.  Those  in  the  upper  jaw,  are  two  central  in- 
cisors, one  lateral  and  two  bicuspids^  on  the  right  side. 
Those  in  the  lower,  are  the  four  incisors,  one  cuspidatus  and 
one  molar.  Their  appearance  is  that  of  bone^  extremely 
rough,  without  any  coating  or  enamel,  and  of  a  dingy  brown 
color." 

Tavo  cases  somewhat  like  the  foregoing,  have  come  under 
the  author's  observation.  The  subject  of  the  first  was  a 
shoemaker,  Mr.  M.,  of  Baltimore,  who  erupted  a  lateral  in- 
cisor and  cuspidatus  at  the  age  of  thirty.  Two  years  before 
this  time,  he  had  been  badly  salivated,  and,  in  consequence, 
lost  four  upper  incisors,  and  one  cuspid.  The  alveoli  of 
these  teeth  exfoliated,  and_,  at  the  time  he  first  saw  him, 
were  entirely  detached  from  the  jaw  and  barel}''  retained  in 
the  mouth  by  their  adhesion  to  the  gums.  On  removing 
them,  he  found  two  white  bony  protuberances,  which,  on 
examination,  proved  to  be  the  crowns  of  an  incisor  and  cus- 
pidatus.    They  were  perfectly  formed,  and  though  much 

*  Dr.  J.  D.  McCabe. 


THIRD   DENTITION.  193 

shorter  than  the  other  teeth,  yet^  up  to  the  present  time, 
1845j  have  remained  quite  firm  in  the  jaw. 

The  subject  of  the  other  case,  was  a  lady,  residing  near 
Fredericksburg^  Virginia,  who  erupted  four  right  central 
incisors  of  the  upper  jaw  successively.  One  of  her  temporary 
teeth,  in  the  first  instance,  had  been  permitted  to  remain  too 
long  in  the  mouth,  and  a  permanent  central  incisor,  in  con- 
sequence, came  out  in  front  of  the  dental  arch.  To  remedy 
this  deformity,  the  deciduous  incisor  was,  after  some  delay, 
removed  ;  and,  about  two  years  after,  the  permanent  tooth, 
not  having  fallen  back  into  its  proper  place,  was  also  ex- 
tracted. Another  two  years  having  elapsed,  another  tooth 
came  out  in  the  same  place,  and  in  the  same  manner  ;  and, 
for  similar  reasons,  was  also  removed.  To  the  astonishment 
of  the  lady  and  her  friends,  a  fourth  incisor  made  its  appear- 
ance in  the  same  place,  two  years  and  a  half  after  the  ex- 
traction of  the  first  permanent  tooth.  When  it  had  been 
out  about  eighteen  months,  the  author  was  called  in  by  the 
lady,  who  wished  him,  if  possible,  to  adjust  it.  Finding 
that  it  could  not  be  brought  within  the  dental  circle,  he  ad- 
vised her  to  have  it  extracted,  and  an  artificial  tooth  placed 
in  the  proper  place  in  the  arch. 

In  the  second  number  of  the  eighth  volume  of  the  Amer- 
ican Journal  of  Dental  Science,  the  history  of  a  case  of  four 
successive  dentitions  of  the  upper  central  incisors  is  given.* 

It  is  said  that  the  efforts  made  by  nature,  for  the  produc- 
tion of  a  third  complete  set  of  teeth,  are  so  great,  that  they 
exhaust  the  remaining  energies  of  the  system  ;  and  as  a 
consequence,  that  occurrences  of  this  kind  are  generally  soon 
followed  by  death. 

The  author  is  not  aware  that  any  attempt  has  ever  been 
made  to  explain  the  manner  of  the  origin  and  formation  of 
the  teeth  of  third  dentition.  The  rudiments  of  the  teeth  of 
first  and  second  dentition  originate  from  mucous  membrane, 

*  Dr.  W.  H.  Dwindle. 


194  THIRD   DENTITION. 

while  those  of  third  dentition  would  seem  to  he  the  product 
of  the  periosteal  tissue  or  bone. 

In  obedience  to  what  law  of  developmental  anatomy  are 
the  teeth  of  third  dentition  formed  ?  Certainly  not  to  any 
one  primitively  impressed  upon  the  animal  economy^  as  they 
have  never  been  known  to  appear  while  the  teeth  of  second 
dentition  remain  in  the  jaws.  If  the  establishment  of  the 
law  which  governs  the  development  of  a  part,  depends  upon 
a  certain  condition  of  other  contiguous  parts,  it  is  possible 
that  the  following  may  be  a  correct  explanation  of  the 
phenomenon  of  third  dentition.  Certain  parts,  in  certain 
states  or  conditions,  and  in  particular  locations,  perform 
functions  peculiar  to  themselves.  In  other  words,  the  con- 
dition and  location  of  a  part  determines  the  function  or 
functions  it  performs.  For  example,  when  the  mucous 
membrane  along  the  course  of  the  alveolar  border  begins  to 
assume  a  duplicated  or  grooved  condition,  which  it  does  at 
about  the  sixth  week  of  intra-uterine  existence,  dental 
papillfB  shoot  up  from  it,  and  when,  by  a  similar  duplica- 
tion of  this  same  tissue,  behind  the  sacs  of  the  temporary 
teeth,  forming  what  Mr.  Goodsir  styles  ""cavities  of  reserve," 
the  papilla3  of  the  permanent  teeth,  one  from  the  bottom  or 
distal  extremity  of  each  duplication,  begins  to  be  developed. 
Hence,  it  would  seem  that  this  particular  state  or  condition 
of  this  tissue,  and  in  these  particular  locations  is  necessary 
to  determine  the  development  of  teeth  germs.  This  arrang- 
ment  or  condition  of  mucous  membrane,  in  these  particular 
locations,  which  always  result  from  the  development  of  the 
fetus,  may  be  sometimes  produced  by  accidental  causes, 
after  all  the  organs  of  the  body  have  attained  their  full 
size,  or  at  any  time  during  life  ;  and  when  it  does  occur,  it 
is  not  unreasonable  to  suppose  that  a  new  tooth  papilla 
should  be  formed.  Proceeding  still  farther,  the  develop- 
ment of  a  dental  papilla  is  the  signal  for  the  production  of 
a  dental  follicle,  which  ultimately  becomes  a  sac,  and  then 
an  organ  to  supply  the  tooth,  now  considerably  advanced  in 
the  process  of  formation,  with  a  covering  of  enamel.     But 


THIRD   DENTITION.  195 

as  the  maxillary  bone  lias  previously  attained  its  full  size, 
it  rarely,  if  ever,  happens  that  alveoli  are  formed  for  these 
accidental  productions,  and,  consequently,  they  seldom  have 
roots,  or  if  they  do,  they  are  very  short  and  blunt.  They 
are  usually  connected  to  the  periosteum  of  the  alveolar 
border,  and  this  union  is  sometimes  so  close  and  intimate, 
that  very  considerable  force  is  necessary  for  their  removal, 
or  at  least,  so  far  as  our  own  observations  go  upon  the  sub- 
ject, and  we  have  had  occasion  to  extract  several  in  the 
course  of  our  practice.  As  a  general  rule,  however,  they 
loosen  in  the  course  of  a  few  years  and  drop  out. 

But  it  maybe  asked,  how  are  such  accidental  duplications 
of  the  mucous  membrane  formed?  This  is  a  question,  we 
admit,  which  it  may  not  be  easy  to  answer  satisfactorily, 
but  we  do  not  think  it  at  all  improbable,  that  they  some- 
times occur  during  the  curative  process  that  follows  the 
removal  of  one  or  more  teeth.  The  granulated  walls  of  the 
gums  surrounding  an  alveolus  from  which  a  tooth  has  been 
extracted,  may  become  covered  with  this  tissue  before  the 
socket  is  filled  with  a  deposit  of  new  bone,  or,  at  any  rate, 
of  the  surfaces  of  the  duplicated  membrane  near  the  bone, 
and  whenever  such  arrangement  or  condition  of  this  tissue 
takes  place,  upon  the  alveolar  border,  and  that  it  may, 
occasionally,  we  think  there  can  be  no  question,  it  is  proba- 
ble that  a  new  tooth  papilla  is  produced,  which,  in  the 
progress  of  its  development,  induces  the  formation  of  the 
various  appendages  necessary  to  tlie  production  of  a  per- 
fect tooth. 

This,  in  the  opinion  of  the  author,  is  the  only  way  that 
these  fortuitous  productions  can  be  accounted  for  in  accord- 
ance with  true  physiological  principles.  It  seems  impossible 
to  exi^lain  the  manner  of  their  formation  in  any  other  way. 
All  must  admit  that  the  presence  of  mucous  membrane  is 
necessary,  and  we  cannot  conceive  of  any  other  way  by  which 
its  presence  beneath  the  general  surface  of  the  gums  can  be 
accounted  for ;  but  if  we  admit  this  explanation  to  be  correct, 
the  question  is  at  once  solved.    We  believe  it  is  also  owing  to 


196  THIRD    DENTITION. 

the  accidental  occurrence  of  a  certain  arrangement  or  condi- 
tion of  the  mucous  membrane  concerned  in  the  production 
of  the  permanent  teeth,  consisting,  most  likely,  of  the  for- 
mation of  one  or  more  '^cavities  of  reserve"  than  is  called 
for  by  the  teeth  of  this  dentition,  that  the  development  of 
supernumerary  teeth  are  attributable. 

The  operations  of  nature,  it  is  true,  are  so  secretly  carried 
on,  that  we  cannot  see  the  precise  modus  operandi  by  which 
they  are  effected,  yet  in  the  development  of  the  various 
organs  and  structures  of  the  body,  we  may  see  them  at  the 
various  stages  of  their  growth,  as  well  as  what  precedes 
their  arrival  at  these  various  stages  in  the  progress  of  their 
formation,  and  upon  which  their  accretion  would  seem  to  be 
dependent.  The  periods  for  the  arrival  of  these  stages  of 
development,  though  somewhat  irregular,  occur  for  the 
most  part,  in  normal  conditions  of  the  body,  at  certain 
fixed  epochs.  Thus,  the  papilla  of  the  first  temporary 
molar  may  usually  be  seen  between  the  sixth  and  seventh 
weeks  of  intra-uterine  existence,  but  previously  to  this  time 
a  slight  groove  or  depression  is  observable  in  the  mucous 
membrane  of  the  part  from  whence  it  has  its  origin.  The 
same  is  true  with  regard  to  the  papillae  of  all  the  other 
teeth,  though  the  time  for  the  commencement  of  their  for- 
mation occurs  at  later  periods.  The  peculiar  change  which 
takes  place  in  the  arrangement  of  the  mucous  tissue  here, 
as  well  as  the  periods  at  which  they  occur,  is  doubtless 
determined  by  certain  stages  in  the  development  of  other 
parts,  and  these  very  likely,  may  determine  the  established 
number  which  the  teeth  of  both  dentitions  have. 

If  the  foregoing  views  which  we  have  advanced  be  correct, 
these  fortuitous  productions  are  not  the  result  of  a  mere 
freak  of  nature,  as  they  are  sometimes  facetiously  styled. 
They  are  the  result  of  the  operation  of  an  established  law  of 
the  economy ;  and  although,  after  the  completion  of  the 
teeth  of  second  dentition,  its  course  is  suspended,  the  occur- 
rence of  a  similar  arrangement  or  condition  of  the  mucous 
tissue  in  the  parts  in  question,  will  again  put  it  in  operation. 


I 


PA.KT    SECOISTD, 


PHYSICAL    OIIARACTERISTICS 

OF  THE  HUMAN  TEETH  AND  GUMS, 

THE    SALIVARY    CALCULUS, 

THE  LIPS  AND  TONGUE, 

AND  THE  FLUIDS  OF  THE  MOUTH. 


I>^RT     SECOND. 


CHAPTER    FIRST. 
GENERAL    CONSIDERATIONS. 

The  susceptibility  of  the  human  body  to  morbid  impres- 
sions differs  in  different  individuals.  In  some,  its  function- 
al operations  are  liable  to  be  deranged  from  the  most  tri- 
fling causes;  in  others,  they  are  less  easily  disturbed.  Nor 
do  the  same  causes  always  produce  the  same  results.  Their 
effects  are  determined  by  the  tendency  of  the  organism  and 
the  suscei^tibility  of  the  part  on  which  they  act ;  and  this  is 
true,  both  with  regard  to  constitutional  and  local  dis- 
eases :  with  the  organism  generally  and  all  its  parts  sepa- 
rately considered,  but  with  none  more  than  the  teeth,  gums 
and  alveolar  processes.  The  teeth  of  some  persons  are  so 
susceptible  to  the  action  of  corrosive  agents^  as  to  become 
involved  in  general  and  rajnd  decay,  as  soon  as  they  emerge 
from  the  gums  ;  while  those  of  others,  though  exposed  to 
the  same  causes,  remain  unaffected  through  life.  A  simi- 
lar difference  of  susceptibility  also  exists  in  the  parts  within 
which  these  organs  are  contained. 

With  the  teeth,  these  differences  of  susceptibility  to  mor- 
bid impressions^  are  implanted  in  them  at  the  time  of  their 
formation,  and  are  the  result  of  the  different  degrees  of  per- 
fection in  which  this  process  is  accomplished.  In  proportion 
as  these  organs  are  perfect,  is  their  capability  of  resisting 
the  action  of  destructive  agents  increased,  and  as  they  are 


200  GENERAL   CONSIDERATIONS. 

otherwise,  it  is  diminislied.  This  is  true  of  every  part  ol 
the  body ;  hut  as  the  teeth  are  formed,  so  they  continue 
through  life,  if  not  impaired  hy  disease,  except  that  they 
gradually  acquire  a  very  slight  increase  of  density,  whereby 
their  liability  to  caries  is  correspondingly  lessened. 
■  Not  so,  however,  with  the  other  parts  of  the  body.  They 
may  be  innately  delicate,  or  imperfectly  developed^  and  af- 
terwards become  firm  and  strong,  or  be  at  first  healthy  and 
well  formed,  and  subsequently  become  impaired ;  and  in 
proportion  as  they  undergo  these  changes,  is  their  suscepti- 
bility of  disease,  increased  or  diminished.  But  the  teeth 
are  not  governed  by  the  same  laws,  neither  physical  nor 
vital,  that  regulate  the  operations  of  the  other  parts  of  the 
animal  economy.  Not  only  is  the  manner  of  their  forma- 
tion, but  their  diseases,  also,  are  different.  The  other  tis- 
sues of  the  body,  not  excepting  the  osseous,  are  endowed 
with  recuperative  powers,  whereby  an  injury  is  repaired  by 
their  own  inherent  energies,  but  the  teeth  do  not  possess 
such  attributes. 

Assuming  these  propositions  to  be  true,  and  that  they  are, 
especially  those  with  regard  to  the  teeth,  as  we  shall  en- 
deavor to  show,  it  becomes  an  object  of  considerable  import- 
ance to  discover  the  signs  by  which  the  susceptibility  of  the 
human  organism  to  disease,  may  be  determined.  But  to  do 
this,  except  in  so  far  as  the  teeth,  gums  and  alveolar  pro- 
cesses are  concerned,  is  not  our  present  object,  yet,  in  the 
prosecution  of  the  task  we  have  undertaken,  we  may  have 
occasion  to  advert  to  certain  constitutional  and  local  tenden- 
cies, indicated  by  the  appearance  and  condition  of  the  teeth 
and  other  parts  of  the  mouth. 

M,  Delabarre  affirms,  that  by  an  inspection  of  the  teeth, 
we  can  ascertain  whether  the  innayte  constitution  is  good  or 
bad,  and  our  own  observations  go  to  confirm  the  truth  of  this 
opinion  ;  but  as  this  author  adds,  these  are  not  the  only  or- 
gans that  should  be  interrogated.  The  lips,  the  gums,  the 
tongue,  and  the  fluids  of  the  mouth  should  also  be  examined 
to  discover  the  health  of  the  organism,  and  ascertain  wheth- 


GENERAL  CONSIDERATIONS,  201 

er  tlie  original  condition  of  the  constitution  has  undergone 
any  change. 

Those  who  have  not  been  in  the  constant  habit  of  closely 
observing  the  appearances  met  with  in  the  mouth,  may  be 
sceptical  with  regard  to  the  information  that  may  thus  be 
derived,  but  those  who  have  studied  them  with  care,  will 
not  hesitate  to  say,  that  they  are,  in  many  instances,  more 
certain  and  accurate  than  any  which  can  be  obtained  from 
other  physical  appearances.  For  example — the  periods  of 
the  dentinification  of  the  different  classes  of  both  sets  of 
teeth  being  kuoAvn,  we  are  enabled  to  say  whether  the  in- 
nate constitution  is  good  or  bad  by  the  physical  condition 
of  these  organs,  for  as  the  functions  of  the  organism  are  at 
this  time  healthily  or  unhealthily  performed,  will  they  be 
perfect  or  imperfect;  or  in  other  words,  will  their  texture 
be  hard  or  soft. 

It  is  well  known  to  writers  on  odontology,  that  the  teeth  of 
the  child,  like  other  parts  of  the  body,  usually  resemble  those 
of  its  parents,  so  that  when  those  of  the  father  or  mother  are 
bad  or  irregularly  arranged,  a  similar  imperfection  is  gen- 
erally found  to  exist  in  those  of  the  offspring,  but  this  does 
not  necessarily  follow,  and  when  it  does,  it  is  the  result  of 
the  transmission  of  some  constitutional  impairment,  where- 
by the  formative  operation  of  these  organs  is  either  dis- 
turbed or  prevented  from  being  effected  in  a  perfect  and 
healthy  manner.  The  teeth  of  the  child,  therefore,  may  be 
said  to  depend  on  the  health  of  the  mother,  and  the  ali- 
ment from  which  it  derives  it  subsistence.  If  the  mother  is 
healthy,  and  the  nourishment  of  the  child  be  of  good  quali- 
ty, the  teeth  will  be  dense  and  compact  in  their  texture, 
generally  Avell  formed  and  well  arranged,  and  as  a  conse- 
quence less  liable  to  be  acted  on  by  morbid  secretions, 
than  those  of  children  deriving  their  being  from  unhealthy 
mothers,  and  subsisting  upon  aliment  of  a  bad  quality. 
Temperament,  also,  exercises  an  influence  upon  the  func- 
tional operations  of  the  body.  Upon  it  the  constitutional 
health  depends  to  a  greater  extent  than  pathologists  gener_ 
14 


202  GENERAL  CONSIDERATIONS. 

ally  admit,  and  lieuce  it  is,  that  that  of  the  child  usually 
partakes  of  that  of  one  or  other,  or  both,  of  its  parents. 
"This,"  says  M.  Delabarre,  "is  particularly  observable  in 
subjects  that  have  been  suckled  by  a  mother  or  nurse  whose 
temperament  was  similar  to  theirs."  To  obviate  the  en- 
tailment of  this  evil,  he  recommends  mothers,  having  teeth 
constitutionally  bad,  to  abstain  from  suckling,  and  that  this 
highly  important  office  be  entrusted  to  a  nurse  having  good 
teeth — asserting  at  the  same  time,  that  by  this  means,  the 
transmission  of  so  troublesome  a  heritage  as  bad  teeth,  may 
be  avoided. 

Depending,  then,  as  the  i:)hysical  condition  of  the  teeth, 
and  the  organism  generally,  confessedly  do,  upon  the  quali- 
ty of  the  nourishment  from  which  subsistence  is  derived 
during  infancy  and  childhood,  it  is  highly  essential  that 
this  be  good,  and  that  that,  especially,  derived  from  the 
breast,  be  from  those  only  who  are  in  the  enjoyment  of  j^er- 
fect  health,  and  possess  good  constitutions. 

Delabarre  says,  that  a  child,  though  it  derives  its  being 
from  weakly  parents,  may,  by  proper  regimen,  acquire  a 
good  constitution  and  temperament.  M.  Mahon,  a  French 
dentist,  and  author  of  considerable  acumen  and  celebrity, 
affirms,  that  a  person  cannot  be  born  with  a  good  constitu- 
tion, except  those  from  whom  he  derives  his  being  are  in 
good  health,  and  of  that  age  when  life  is  vigorous.  But  he 
admits,  that  a  child  coming  from  parents  of  the  most  per- 
fect health,  may  have  its  constitution  deteriorated  by  im- 
pure lactation  :  and  that  a  child  coming  from  weakly  pa- 
rents, may  acquire  a  good  constitution,  though  it  will  al- 
ways bear  about  it  certain  signs  of  that  which  it  had  inher- 
ited— and  thence,  he  deduces  tiiat  it  is  possible  to  discover, 
by  an  examination  of  the  teeth,  any  tendencies  that  may  be 
lurking  in  the  system.  He  has  certainly  studied  the  sub- 
ject very  attentively,  and  his  remarks  are  worthy  of  consid- 
eration. If  all  he  says  is  not  true,  many  of  his  observa- 
tions, we  think,  are  susceptible  of  proof. 

In  treating  upon  the  pliysiognomical  indications  of  the 


GENERAL   CONSIDERATIONS.  203 

teeth,  the  last  named  author  says  :  ''Does  the  child  derive 
its  life  from  parents  that  are  unhealthy  ?  The  enamel  of 
its  milk  teeth  will  be  bad  ;  the  teeth,  themselves,  will  be 
surcharged  with  a  bluish  vapor^  and  in  a  short  time,  will  be 
corrupted  by  a  humid  and  putrefying  caries.  When  the 
parents  are  only  weakly  or  delicate,  the  enamel  of  the  pri- 
mary teeth  will  have  a  bluish  appearance,  there  will  be  a 
tendency  in  them  to  dry  caries,  which  does  not  ordinarily 
make  much  progress,  and  seldom  causes  pain." 

Again_,  he  observes,  "It  was  only  by  a  determination  to 
notice  very  accurately  the  ditferences  which  I  remarked  on 
the  teeth  of  numerous  individuals,  that  I  obtained  these 
first  truths.  In  the  first  instance,,  they  were  little  more 
than  mere  conjectures,  but  by  being  daily  increased,  have 
now  become  diagnostics^  about  the  certainty  of  which,  I  flat- 
ter myself,  I  cannot  be  deceived.  It  affords  me  pleasure  to 
give  an  account  in  this  place  of  a  part  of  the  means  which 
I  em^Dloyed  to  arrive  at  the  point  which  was  the  object  of 
my  researches.  When  I  perceived  some  signs,  as  for  ex- 
ample, shadowy  lines  on  the  primary  teeth,  and  those  of 
replacement,  of  different  children,  I  put  all  my  application 
to  work  for  the  ascertainment  of  their  cause^  and  when  I 
believed  I  had  found  it,  I  interrogated  their  mothers,  who 
generally  confirmed  the  judgment  I  had  formed.  I  then 
Avent  on  further  ;  after  calculations  that  seemed  to  me  highly 
probable,  I  ventured  to  declare  the  period  at  which  a  great 
crisis  or  disease  had  happened,  and  in  such  a  month  of  preg- 
nancy ;  and  I  have  had  the  satisfaction  to  find  that  I  had 
conjectured  correctly.  My  expectations,  based  upon  the 
same  procedure,  have  been  crowned  with  success  in  adults, 
whose  teeth,  by  the  simple  examination  of  them,  have  dis- 
closed to  me  an  advantage  no  less  valuable  than  the  first, 
namely,  that  of  generally  being  able  to  tell;,  whether  they 
were  born  of  strong,  weak,  or  aged  parents  ;  and  also,  if 
the  mother  has  had  several  children,  whether  they  were 
among  the  last,"  etc. 

That  a  person  experienced  in  such  researches,  may,  by  an 


204  GENERAL   CONSIDERATIONS. 

examination  of  the  deciduous  teeth,  tell  whether  the  mother, 
during  the  latter  periods  of  pregnancy,  had  enjoyed  good 
or  bad  health,  there  is  no  question.  But  it  is  very  doubtful 
whether  much  can  be  ascertained,  by  an  inspection  of  the 
milk  teeth,  concerning  the  health  of  the  mother  previously 
to  the  time  of  the  commencement  of  their  solidification, 
for  upon  the  manner  in  which  this  is  effected,  depends  their 
appearance  and  physical  condition.  The  density  of  a  tooth 
may  be  told  at  a  single  glance  by  a  practiced  observer,  and 
it  is  this  and  its  color  that  are  principally  influenced  by  the 
condition  of  the  system  during  their  solidification.  The 
shape  of  the  teeth  is  determined  by  that  of  the  jaws  and 
pulps  before  the  commencement  of  this  process. 

We  are  of  opinion,  therefore,  that  nothing  positive,  con- 
cerning the  health  of  the  mother  during  the  first  five  or  six 
months  of  pregnancy,  can  be  learned  from  an  inspection  of 
the  teeth  of  either  dentition.  From  an  inspection  of  those 
of  the  second,  no  information  whatever  in  relation  to  it  can 
be  derived,  and  if  Mahon  was  fortunate  enough  in  some  in- 
stances to  tell  what  it  had  been  at  an  earlier  period,  his 
prognosis  could  not  have  been  founded  upon  any  thing  more 
than  mere  conjecture. 

The  teeth  wliile  in  a  pulpy  state  partake  of  the  health  of 
the  organism  generally.  As  that  is  healthy  and  strong,  or 
unhealthy  and  weak^  so  will  the  elementery  principles  of 
which  they  are  then  composed,  be  of  a  good  quality,  or  de- 
teriorated, but  after  dentinification  has  commenced,  the 
solid  parts  cease  to  be  influenced  by,  or  to  obey  the  laws  of 
the  other  parts  of  the  body.  If  the  general  health  be  good 
at  the  time  this  process  is  going  on,  it  will  be  evidenced  in 
their  density  and  color  ;  if  bad,  in  the  looseness  of  their 
texture,  etc. 

This  is  a  subject  to  which  we  have  jiaid  some  attention, 
having  for  a  long  time  been  in  the  habit  of  carefully  noting 
the  diff'erences  in  the  appearance  of  the  teeth  of  diff'erent 
individuals,  and  of  both  dentitions,  and  though  we  have 
been  able  to  conjecture  in  some  instances  what  had  been  the 


GENERAL  CONSIDERATIONS.  205 

state  of  tlie  mother's  health  during  the  first  mouths  of 
pregnancy,  candor  compels  us  to  confess^  that  we  have  never 
been  able  to  find  any  signs  in  the  peculiarity  of  their  shape, 
size,  density,  or  arrangement,  that  indicated  it.  But  from 
the  moment  that  that  part  of  the  formative  process  of  these 
organs  commences,  which  is  not  influenced  by  subsequent 
changes  in  the  general  economy,  certain  peculiarities  of  ap- 
pearance are  impressed  upon  them  that  continue  through 
life,  and  about  the  certainty  of  the  indications  of  which, 
in  regard  to  the  general  healthy  we  think  there  can  be  no 
doubt. 

In  commenting  upon  the  views  which  M.  Mahon  advances 
upon  this  subject,  Delabarre  says,*  "if  he  had  thrown  the 
light  of  repeated  dissections  upon  them,  he  would  have 
acknowledged,  with  Hunter,  Blake,  Maury,  Fox  and  Bunon, 
that  the  secondary  teeth  do  not  begin  to  ossify  until  about  the 
sixteenth  month  after  birth,  so  that  the  good  or  bad  health 
of  the  parents  at  the  time  of  conception,  cannot  in  any  way 
affect  the  teeth  of  replacement,  which  are  not  formed  until 
after  the  child  comes  into  the  world." 

But,  however  vague  and  erroneous  may  be  some  of  the 
opinions  of  Mahon,  he  has  certainly  advanced  many  that 
are  correct,  and  from  which,  hints  have  been  derived  that 
have  formed  the  foundation  of  some  very  valuable  contribu- 
tions to  the  science  of  the  semeiology  of  the  teeth. 

Lavater  was  laughed  at  and  ridiculed  for  his  enthusiastic 
belief  in  physiognomy,  but  the  description  which  he  gives, 
with  a  view  to  the  illustration  of  his  favorite  science,  of  the 
physical  conformation  of  the  various  parts  of  the  face,  head, 
and  other  portions  of  the  organism  of  man,  embrace  signs, 
which,  if  applied  to  the  study  of  semeiology,  could  hardly 
fail  to  lead  to  important  results.  Had  the  education  and 
pursuits  of  this  good  and  extraordinary  man,  fitted  him  for 
the  investigation  of  this  department  of  medical  science,  and 
had  he  entered  into  it  with  the  same  persevering  ardor  and 

*  Vide  Seimeitique  Buccale,  p.  225. 


206  GENERAL  CONSIDERATIONS. 

zeal  he  did  that  of  physiognomy,  he  would  have  erected  for 
himself  an  equally  enduring  monument  of  fame,  and  would 
thus  perhaps  have  contributed  as  much  to  the  amelioration 
of  the  condition  of  his  fellows,  as  he  has  done  by  his  physi- 
ognomical researches.  In  fact^  of  the  importance  of  this 
subject,  he  seems  to  have  been  fully  aware ;  and,  after 
acknowledging  his  ignorance,  he  says^  the  physiognomical 
and  pathognomical  semeiotica  of  health  and  disease  ought  to 
be  treated  on  by  an  experienced  physician,  stating,  that 
from  the  few  observations  which  he  had  made,  it  was  not 
difficult  to  discover  the  diseases  to  which  an  individual  in 
health  is  most  liable.  He  regards  physiognomical  sem- 
eiotics,  founded  upon  the  nature  and  form  of  the  body,  as  of 
great  importance  to  the  medical  practitioner,  that  he  may 
be  able  to  say  to  an  individual  in  health,  you  may  expect 
this  or  that  disease  some  time  in  your  life.  Possessed  of 
this  knowledge,  he  would  be  able  to  prescribe  the  necessary 
preventives  or  precautions  against  such  diseases  as  he  is 
most  liable  to  contract. 

Among  the  signs  which  he  notes  as  indicative  of  the 
temperament,  he  enumerates  the  shape^  size  and  arrange- 
ment of  the  teeth,  but  from  the  physical  characteristics  of 
these  organs,  when  considered  separately  from  other  parts  of 
the  mouth,  we  only  learn  what  the  innate  constitution  was; 
they  cannot  be  relied  upon  as  indices  to  the  state  of  the 
health  subsequently  to  the  time  of  their  solidification. 
Their  own  liability  to  disease,  however,  may  be  determined 
by  their  appearance,  and  with  the  signs,  therefore^  indica- 
tive of  this,  every  dentist  should  be  familiar,  to  enable  him, 
when  consulted  with  regard  to  the  attention  necessary  to 
the  preservation  of  these  organs,  to  prescribe  such  precau- 
tionary measures  as  will  secure  them  against  the  attacks  of 
disease. 

With  regard,  also,  to  the  information  to  be  derived  from 
an  inspection  of  the  teeth,  concerning  the  innate  constitu- 
tion, it  has  been  well  remarked  by  Delabarre,  that  physi- 
cians may  derive  much  advantage  in  pointing  out  the  rules 


GENERAL  CONSIDERATIONS.  207 

of  domestic  hygiene  for  the  physical  education  of  children  ; 
for,  says  this  eminent  dentist,  ''can  he  admit  of  but  one 
mode?  Has  he  not,  then,  the  greatest  interest  to  be  well 
assured  of  the  innate  constitution  of  each,  for  whom  his 
advice  is  required,  to  enable  him  to  recommend  nutriment 
suited  to  the  strength  of  its  organs?  Will  he  report  only 
on  a  superficial  examination  of  the  face,  its  paleness,  the 
color  of  the  skin,  all  of  which  are  variable?  Will  he  not 
regard  the  repletion  or  leanness  of  the  subject,  the  state  of 
the  jDulse,  &c.?  Surely  he  will  make  good  inductions  from 
all  these  things  ;  but  the  minute  examination  of  the  mouth 
will  give  him,  beyond  doubt,  the  means  of  confirming  his 
judgment ;  for,  besides  what  we  already  know  of  the  teeth, 
the  mucous  membrane  of  the  buccal  cavity  receives  its  color 
from  the  bloody  and  varies  according  to  the  state  of  that 
fluid."  This  is  a  matter  which  the  observation  of  the  den- 
tist has  an  opportunity  of  confirming,  almost  every  day  ; 
and  which,  when  taken  in  connection  with  the  physical 
characteristics  of  the  teeth,  together  with  those  of  the  sali- 
vary and  mucous  secretions  of  the  mouth,  constitute  data, 
from  which  both  the  innate  and  present  state  of  the  consti- 
tutional health  may  be  determined  with  accuracy  and  cer- 
tainty. 

The  symptoms  of  actual  disease  have  been  minutely  and 
repeatedly  described,  but  the  physiognomical  signs  by  which 
the  susceptibility  of  the  human  organism  to  morbid  impres- 
sions is  determined,  and  the  kind  of  malady  most  liable  to 
result  therefrom_,  do  not  appear  to  be  so  well  understood. 
''Whatever,"  says  the  author  last  quoted,  "may  be  the 
knowledge  which  a  practitioner  may  acquire  of  the  changes 
a  disease,  or  even  a  tendency  to  disease,  may  effect  in  the 
use  of  the  functions  of  some  organs,  it  is,  at  least_,  advanta- 
geous to  be  able  to  conjecture  what  has  happened,  in  the 
whole  of  the  system  at  another  time.  In  fact,  can  a  physi- 
cian, when  about  to  prescribe  for  a  slight  indisposition  of  a 
person  whom  he  hardly  knows,  rely  entirely  upon  the  sabu- 
lous state  of  the  tongue  ?     Does  not  its  aspect  singularly 


208  GENERAL   CONSIDERATIONS. 

vary?  Is  it  not  notorious,  that  in  certain  persons  it  is 
always  red,  white,  yellow  or  blackish  ?  I,  as  well  as  others, 
have  had  occasion  to  make  these  observations  on  persons 
with  whom  it  was  always  thus,  but  without  their  being  sub- 
ject to  any  of  those  indispositions  that  are  so  common  in  the 
course  of  life."  These  signs  are  as  variable  in  sickness,  as 
in  health,  and,  consequently,  can  only  be  relied  upon  as 
confirmatory  of  the  correctness  of  other  indications  which 
manifest  themselves  in  other  parts  of  the  body. 

The  physical  changes  produced  by,  and  characteristics  of, 
disease,  have  been  described,  both  by  ancient  and  modern 
medical  writers,  but  the  works  which  have  appeared  upon 
this  subject,  do  not  comprise  all  that  is  necessary  to  be 
known.  For  example — if  we  examine  the  lips,  tongue  and 
gums  of  a  dozen  or  more  individuals  who  are  regarded  as  in 
health,  differences  in  their  appearance  and  condition  will  be 
found  to  exist.  The  lips  of  some  will  be  red,  soft  and  thin ; 
others  red,  thick,  and  of  a  firm  texture  ;  some  will  be 
thin  and  pale  ;  others  red  on  the  inside  and  pale  on  the 
edges  ; — some  are  constantly  bathed  with  the  fluids  of  the 
mouth  ;  others  are  dry,  and  these  differences  of  appearance 
and  condition  are  as  marked  on  the  tongue  and  gums  as  they 
are  upon  the  lips,  and  are  supposed  to  be  attributable  to  the 
preponderance  or  want  of  existence  in  sufiicient  quantity  of 
some  one  or  more  of  the  elementary  principles  of  the  organ- 
ism. Hence,  may  be  said  to  result  the  differences  in  tem- 
perament and  susceptibility  of  the  body  to  the  action  of 
morbid  excitants. 

Tlie  body,  says  Lavater,  is  composed,  after  an  established 
manner,  "of  various  congruous  and  incongruous  ingre- 
dients." He  also  believes  ''that  there  is,"  to  use  the  meta- 
phor, "a  particular  recipe,  or  form  of  mixture,  in  the  great 
dispensatory  of  God,  for  each  individual,  by  which  his 
quantity  of  life,  his  kind  of  sensation,  his  capacity  and  ac- 
tivity are  determined  ;  and  that,  consequently,  each  body 
has  its  individual  tempevament,  or  peculiar  degree  of  irrita- 
bility.    That  the  humid  and  the  dry,  the  hot  and  the  cold 


GENERAL  CONSIDERATIONS.  209 

''are  tlie  four  principal  qualities  of  the  corporeal  ingre- 
dients, is  as  undeniable  as  that  earth  and  water,  fire  and  air, 
are  themselves  the  four  principal  ingredients."  "Hence," 
he  argues,  ''that  there  will  he  four  principal  temperaments; 
the  choleric,  originating  from  the  hot';  the  phlegmatic,  from 
the  moist ;  the  sanguine,  from  air  ;  and  the  melancholic, 
from  earth ;  that  is  to  say^  that  these  predominate  in,  or 
are  incorporated  with,  the  blood,  nerves  and  juices,  and  in- 
deed in  the  latter,  in  the  most  subtile,  and  almost  spiritually 
active  form.  But  it  is  equally  indubitable  to  me,  that  these 
four  temperaments  are  so  intermingled  that  innumerable 
others  must  arise,  and  that  it  is  frequently  difficult  to  dis- 
cover which  preponderates  ;  especially  since,  from  the  com- 
bination and  interchangeable  attraction  of  those  ingredients, 
a  new  power  may  originate,  or  be  put  in  motion,  the  char- 
acter of  which  may  be  entirely  distinct  from  that  of  the  two 
or  three  intermingling  ingredients."  The  truth  of  these 
propositions  will  hardly  be  questioned,  and  their  admission 
at  once  affords  a  satisfactory  explanation  of  the  differences 
in  the  susceptibility  of  different  organisms  to  the  attacks  of 
disease. 

Admitting  the  foregoing  statement  to  be  correct,  we  think 
it  may  be  safely  assumed,  that  if  the  quality  and  respective 
proportions  of  the  materials  furnished  for  the  growth,  repa- 
ration and  maintenance  of  the  several  organs  of  the  body, 
be  good,  and  in  proper  proportion,  all  the  organs  will  be 
well  formed  and  endowed  with  health,  and,  as  a  conse- 
quence, capable  of  j^erforming  their  respective  functions  in 
a  healthy  manner.  But  if  their  elementary  ingredients,  to 
use  an  expression  of  the  author  from  whom  we  have  just 
quoted,  be  bad,  their  functions  will  be  more  or  less  feebly 
performed. 

These  materials  are  furnished  by  the  blood.*  From  this 
fluid,  each  organ  receives  such  as  are  necessary  to  its  own 

*  Of  the  various  writers  who  have  treated  upon  this  fluid,  Magendie  ranks  de- 
servedly high.  He  instituted  a  great  variety  of  experiments  upon  animals,  which 
go  to  prove,  conclusively,  that  no  one  of  its  constituents  can  be  dispensed  with 


210  GENERAL   CONSIDERATIONS. 

particular  organization.  The  blood,  therefore,  exercises  an 
important  influence  upon  the  whole  mechanism — determin- 
ing the  state  of  the  health  of  all  its  parts,  which,  as  Dela- 
barre  observes,  is  relative  to  its  quality,  and  "that  the  gen- 
eral health  results  from  that  of  all  the  system."  In  order 
to  this,  harmony  must  exist  between  all  the  organs,  but  in 
consequence  of  the  great  variety  and  intermingling  of  tem- 
peraments it  rarely  does,  except,  perhaps,,  in  those  in  whom 
the  sanguine  predominates,  and  who  have  not  become  ener- 
vated by  irregular  and  luxurious  living.  Even  when  it 
does  exist,  we  are  by  no  means  certain  that  it  will  continue 
to  do  so  ;  for  exposed  as  the  body  is  to  a  thousand  causes  of 
disease,  its  functional  operations  may,  at  almost  any  mo- 
ment, become  disturbed.  Among  the  civilized  nations  of 
the  earth,  the  peasantry  of  Great  Britain,  probably,  pos- 
sesses as  good  constitutional  temperaments  as  are  anywhere 
to  be  found  ;  and  yet,  with  these  people,  we  are  told,  that 
although  the  sanguinous  predominates  in  a  majority  of 
cases,  it  is  combined  and  intermingled^  in  a  greater  or  less 
degree,  with  others. 

In  all  of  these  modifications  the  blood  plays  an  important 
part :  it  determines  the  temperament  of  the  individual,  and 
as  a  consequence,  the  physical  condition  of  all  the  tissues  of 
the  body  subject  to  the  general  laws  of  the  economy.  But 
the  dependency  of  the  solids  upon  this  fluid  is  only  mutual ; 
it,  also,  is  dependent  upon  them,  and  the  condition  of  the 
one  is  relative  to  that  of  the  other.  The  solids,  if  we  may 
be  permitted  the  use  of  the  metaphor,  are  the  distillery 
of  the  fluids,  while  they,  in  turn,  nourish,  repair,  and 
maintain  the  solids.  A  change,  then^  in  the  condition  of 
one,  is  followed  by  a  corresponding  change  in  the  condition 
of  the  other.  If  the  blood  be  of  an  impure  quality,  or  any 
of  the  ingredients  entering  into  its  composition  exist  in  too 
great  or  too  small  quantity,  it  will  fail  to  supply  the  solids 

■without  manifest  and  serious  injury  to  the  whole  organism— and  that,  it  is  depend- 
ent for  its  living  principles  upon  the  motion  that  is  given  to  it  in  the  circulatory 
system. 


GENERAL   CONSIDERATIONS.  211 

with  the  materials  necessary  to  the  healthful  performance  of 
their  functions,  and,  if  not  actual  disease,  a  tendency  to  it, 
will  be  the  result.  And,  again,  the  purity  of  the  blood  is 
dependent  upon  the  manner  in  which  the  solids  perform 
their  offices.  While,  therefore,  duly  appreciating  the  im- 
portance of  this  fluid,  and  its  existence  in  a  pure  state,  to 
the  general  health  of  the  economy,  we  cannot  ascribe  to  it^ 
regardless  of  the  functions  of  the  solids,  a  controlling  influ- 
ence over  the  organism. 

To  distinguish  all  the  nice  and  varied  shadings  of  tem- 
perament, or  states  of  the  constitutional  health,  by  the 
physiognomical  appearances  of  the  body,  is  perhaps  impos- 
sible, or  can  only  be  done  with  great  difiiculty,  and  by  those 
who  have  been  long  exercised  in  their  observance  ;  but  to 
discover  that  which  predominates  is  not  so  difficult  a  mat- 
ter, and  the  indications  are  nowhere  more  palpably  mani- 
fested than  in  the  mouth.  By  an  inspection  of  the  several 
parts  of  this  cavity,  together  with  its  fluids  and  the  earthy 
matter  found  upon  the  teeth,  we  repeat,  inductions  may  be 
made,  not  only  with  regard  to  the  innate  constitution,  but 
also  with  regard  to  the  present  state  of  health,  serviceable 
both  to  the  dental  and  medical  practitioner  ;  and,  in  the 
further  prosecution  of  this  inquiry,  we  shall  endeavor  to 
point  out  some  of  the  principal  of  the  indications  here  met 
with — the  appearances  by  which  they  are  distinguished,  and 
to  offer  such  other  general  reflections  as  the  subject  may^ 
from  time  to  time,  seem  to  suggest. 


CHAPTER     SECOND. 

PHYSICAL  CHARACTERISTICS  OF  THE  TEETH. 

Most  dental  physiologists  have  observed  the  marked  dif- 
ferences that  exist  in  the  appearances  of  the  teeth,  gums, 
lips,  tongue,  and  secretions  of  the  mouth  of  different  indi- 
viduals ;  and  of  that  earthy  substance,  (commonly  called 
tartar,)  deposited  in  a  greater  or  less  abundance,  on  the  teeth 
of  every  one,  and  though  all  may  not  have  sought  their  eti- 
ology, many  have  had  occasion  to  notice,  at  least,  their  lo- 
cal indications,  and  to  profit  from  the  information  which 
they  have  thus  obtained.  Nor  have  they  failed  to  observe 
that  tlie  volume,  color,  length  and  arrangement  of  the  teeth 
vary,  and  that  these  are  indicative  of  their  susceptibility  to 
disease. 

There  are  five  principal  classes  or  descriptions  of  teeth, 
each  of  which  differs,  in  some  respects,  from  the  others. 

Class  First. — The  teeth  belonging  to  this  class  are  white, 
with  a  light  cream  colored  tinge  near  the  gum,  which  be- 
comes more  and  more  apparent  as  the  subject  advances  in 
age — of  a  medium  size,  rather  short  than  long  ;  those  of 
each  class  of  uniform  dimensions,  and  very  hard.  This  de- 
scription of  teeth  is  most  frequently  met  with  in  persons  of 
sanguinous  temperaments,  or,  at  least,  those  in  whom  this 
l^redominates  ;  they  rarely  decay,  and  are  indicative,  if  not 
of2)erfect  health,  of  a  state  which  bordered  very  closely  on  it 
at  the  time  of  their  dentinification. 

This  description  of  teeth  is,  at  least,  occasionally  found 
among  persons  of  all  nations.  They  are  very  common,  es- 
pecially in  the  middle  classes  of  the  inhabitants  of  England, 


CHARACTERISTICS   OF   THE  TEETH,  213 

Ireland  and  Scotland.  They  are  also  frequently  met  with 
in  some  parts  of  the  United  States,  the  Canadas,  the  moun- 
tainous districts  of  Mexico,  and  so  far  as  we  have  had  an 
opportunity  of  informing  ourself,  in  France,  Kussia,  Prus- 
sia and  Switzerland.  Those  who  have  them,  usually  enjoy 
excellent  health,  and  are  seldom  troubled  with  dysx)epsia  or 
any  of  its  concomitants.  It  is  this  kind  of  teeth,  which 
Lavater  says,  he  has  never  met  with,  except  in  "good, 
acute,  candid,  honest  men,"  and  of  whose  possessors,  it  has 
been  remarked  that  their  stomachs  are  always  willing  to 
digest  whatever  their  teeth  are  ready  to  masticate. 

In  confirmation  of  what  has  before  been  said  with  regard 
to  the  influence  which  the  state  of  the  constitutional  health 
at  the  time  of  the  solidification  of  the  teeth,  exerts  upon 
the  susceptibility  of  these  organs  to  morbid  impressions, 
it  is  only  necessary  to  mention  the  fact,  well  known  and  fre- 
quently alluded  to,  of  the  early  decay  of  a  single  class,  or  a 
pair  of  a  single  class  of  teeth,  in  each  jaw,  while  the  rest, 
possessing  the  characteristics  just  described,  remain  sound 
through  life.  Thus  when  it  happens,  that  a  child,  of  ex- 
cellent constitution,  is  affected  with  any  severe  disease,  the 
teeth  which  are  at  the  time  receiving  their  earthy  salts,  are 
found,  on  their  eruption,  to  differ  from  those  which  have 
received  their  solid  material  at  another  time,  when  the 
operations  of  the  body  were  healthily  performed.  Instead 
of  having  white,  smooth  and  uniform  surface,  they  have  a 
sort  of  chalky  aspect,  or  are  faintly  tinged  with  blue,  and 
are  rougher  and  less  uniform  in  their  surfaces.  Teeth  of 
this  description  are  very  susceptible  to  the  action  of  corro- 
sive agents,  and  as  a  consequence,  rarely  last  long. 

But,  not  willing  to  rest  the  correctness  of  these  views 
upon  mere  hypothesis,  we,  in  a  great  number  of  instances, 
where  we  have  seen  teeth  thus  varying  in  their  physical 
appearance,  taken  pains  to  inquire  of  those  who  had  had 
an  opportunity  of  knowing  the  state  of  the  general  health 
of  the  individuals,  at  tlie  different  periods  of  dcntinifica- 
tion,  and  in  every  case  where  we  have  been  able  to  procure 


214  CHARACTERISTICS   OF    THE  TEETH. 

tlie  desired  information,  it  has  tended  to  the  confirmation  of 
the  opinion  here  advanced.  Nor  have  we  neglected  to  im- 
prove the  many  opportunities  that  have  presented,  in  the 
course  of  a  somewhat  extended  professional  career,  of  mak- 
ing these  observations. 

Although  the  operations  of  the  economy  are  so  secretly 
carried  on,  that  it  is  impossible  to  comprehend  their  mechan- 
ism fully,  it  is  known  that  the  phenomena  resulting  there- 
from, are  influenced  and  modified  by  the  manner  in  which 
they  are  performed.  If  they  are  deranged,  the  blood,  from 
which  the  earthy  materials  forming  the  basis  of  all  the  os- 
seous tissues,  are  derived,  is  deteriorated,  and  furnishes 
these  salts  in  less  abundance  and  of  an  inferior  quality. 
Hence,  teeth  that  solidify  when  the  system  is  under  the  in. 
fluence  of  disease,  do  not  j)ossess  the  characteristics  neces- 
sary to  enable  them  to  resist  the  assaults  of  corrosive  agents, 
to  which  all  teeth  are  more  or  less  exposed,  and  which  rare- 
ly affect  those  that  receive  their  solidifying  ingredients  from 
pure  blood. 

The  calcareous  salts  of  these  organs  are  furnished  by  the 
red  part  of  this  fluid,  and  the  gelatine  is  derived  from  the 
white  or  serous  part ; — "whence,"  as  Delabarre  remarks, 
"it  results  that  the  solidity  of  these  bones  vary  according 
as  the  one  or  tlie  other  of  these  principles  predominates," 
and  the  relative  proportions  of  these  are  regulated  by  the 
state  of  tlie  blood  at  the  time  the  teeth  are  undergoing 
solidification.  In  healthy  subjects,  the  blood  is  composed 
of  about  four  parts  of  crassamentum,  or  clot,  and  one  of 
serum,  but  the  relative  proportions  of  these  are  not  always 
the  same.  Disease  tends  to  diminish  the  red,  and  to  in- 
crease the  white  or  serous  part  of  this  fluid.  SometiTnes 
the  serum  forms  more  than  one-half,  and  as  this  abounds  at 
the  time  of  the  solidification  of  the  teeth,  they  will  be  soft 
in  their  texture,  and  liable  to  decay. 

The  researches  of  Duhamel  show,  that  bones  acquire 
solidity  no  faster  than  the  parts  which  are  about  to  ossify 
become  charged  with  red  blood.     The  experiments  of  Hal- 


CHARACTERISTICS   OF   THE  TEETH.  215 

LER  are  also  confirmatory  of  this  opinion.  And  Delabarre, 
in  remarking  upon  the  dentinification  of  the  teeth,  says, 
'^the  superficial  layer  of  the  pulp  reddens  hefore  it  ossifies, 
whilst  all  below  is  entirely  white  ;  soon  another  layer  red- 
dens, is  ossified^  and  then  whitens^  and  so  on,  successively." 
The  increase  of  density  which  the  teeth  continue  through 
life  very  gradually  to  acquire,  may  seem  to  militate  some- 
what against  this  theory,  as  the  fluid  conveyed  to  the  den- 
tine subsequent  to  solidification,  is  not  so  much  as  even 
tinged  with  red.  But,  that  these  organs  are  capable  of  be- 
ing injected  with  red  blood,  has  been  satisfactorily  shown  ; 
arid  if  teeth  are  capable,  under  any  circumstances,  of  being 
injected  with  red  blood,  is  it  unfair  to  presume,  that  a  por- 
tion of  some  of  the  red  globules  may  become  so  broken 
down  and  reduced  as  occasionally  to  be  carried  into  the  ves- 
sels or  tubuli  of  the  dentine  by  the  impetus  ordinarily  given 
to  this  fluid  by  the  circulatory  apparatus.  The  author  is  of 
the  opinion  that  it  is  not,  and  that  it  is  in  this  way  that  the 
increase  of  density  which  the  teeth  acquire  is  to  be  account- 
ed for.  A  sufficient  quantity  of  these  broken  globules,  he 
would  suppose,  might  be  conveyed  through  the  vessels  of 
the  dentine,  to  efi"ect  the  very  trifling  and  almost  impercep- 
tible increase  of  density  it  acquires,  subsequently  to  den- 
tinification. This  hypothesis,  he  is  aware,  does  not  accord 
with  the  views  of  Hunter  in  regard  to  the  organization  of 
the  teeth,  nor  with  those  of  several  modern  Euroijean  writ- 
ers on  odontology,  who  maintain  that  these  organs  are  not 
endowed  with  vascularity,  but  the  incorrectness  of  this  doc- 
trine has,  we  think,  been  satisfactorily  shown. 

Class  Second. — Having  digressed  thus  far,  we  shall  now 
proceed  to  notice  the  teeth  belonging  to  the  second  class. 
They  have  a  faint  azure  blue  appearance ;  are  rather  long 
than  short ;  the  incisors  are  generally  thin  and  narrow ;  the 
cuspids  are  usually  round  and  pointed ;  the  bicuspids  and 
molars  small  in  circumference,  with   prominent  cusps  and 


216  CHARACTERISTICS   OF   THE   TEETH. 

protuberances  upon  tlieir  grinding  surfaces.    In  some  cases, 
the  lateral  incisors  are  very  small  and  pointed. 

Teeth  possessing  these  characteristics  are  usually  very 
sensitive,  more  easily  acted  upon  by  corrosive  agents  than 
teeth  of  the  first  class,  and  to  the  ravages  of  which,  unless 
great  attention  is  paid  to  their  cleanliness,  they  often 
fall  early  victims.  They  are  more  frequently  afiected  with 
atrophy,  or  have  upon  their  surfaces  white^  brown  or  opaque 
spots,  varying  in  size  and  number ;  several  are  sometimes 
found  ujjon  a  single  tooth,  and  in  some  instances  every  tooth 
in  the  mouth  is  more  or  less  marked  with  them. 

But  this  is  not  the  only  description  of  teeth  liable  to  be 
afiected  with  this  disease.  These  spots  are  occasionally 
met  with  on  teeth  of  every  degree  of  density _,  shape,  shade 
and  size,  but  they  are,  probably,  more  frequently  seen  on 
these  than  those  first  described,  and,  besides,  it  often  haj)- 
peus  that  they  are  afiected  with  erosion  on  emerging  from 
the  gums,  and  sometimes,  so  badly  as  to  place  both  their 
restoration  and  preservation  beyond  the  reach  of  art.  This 
species  of  erosion,  or  that  which  occurs  previous  to  the  erup- 
tion of  the  teeth,  is  caused  by  some  diseased  condition  of  the 
fluid  which  surrounds  them  before  they  ai)pear  above  the 
gums,  and  is  denominated  congenital. 

Teeth  like  those  now  under  consideration,  are  indicative 
of  a  weakly,  innate  constitution — of  a  temperament  consid- 
erably removed  from  the  sanguinous — and  of  blood  altogether 
too  serous  to  furnish  materials,  such  as  are  necessary  for 
building  up  a  strong  and  healthy  organism.  They  are 
more  common  to  females  than  males,  though  many  of  the 
latter  have  them.  They  are  met  with  among  people  of  all 
countries,  but  more  frequently  among  those  who  reside  in 
sickly  localities,  and  with  individuals  whose  systems  have 
become  enervated  by  luxurious  living.  In  G-reat  Britain, 
they  are  more  rare  than  in  the  United  States,  and  those 
who  have  them,  seldom  attain  to  a  great  age.  Nevertheless, 
some,  under  the  influence  of  a  judicious  regimen,  and  a  sa- 
lubrious climate,  though  innately  delicate,  do  acquire  a  good 


CHARACTERISTICS  OP  THE  TEETH.  217 

constitution,  and  live  to  a  great  age,  while  the  teeth,  less 
fortunate,  except  the  most  rigid  and  constant  attention 
is  paid  to  the  use  of  the  means  necessary  for  their  pre- 
seryation_,  generally  soon  fall  early  victims  to  the  ravages 
of  disease. 

Class  Third. — The  teeth  of  this  class,,  though  differing  in 
many  of  their  characteristics  from  those  last  described,  are, 
nevertheless,  not  unlike  them  in  texture  and  susceptibility 
to  disease.  They  are  larger  than  teeth  of  the  first  or 
second  class  ;  their  faces  are  rough  and  irregular,  with  pro- 
tuberances, rising,  not  only  from  the  grinding  surfaces  of 
the  bicuspids  and  molars,  but  also,  not  unfrequently,  from 
their  sides,  with  corresi^ondingly  deep  indentations.  They 
have  a  muddy  white  color.  The  crowns  of  the  incisors  of 
both  jaws  are  broad,  long  and  thick.  The  posterior  or  pala- 
tine surfaces  of  those  of  the  superior  maxillary  are  rough, 
and  usually  deeply  indented.  In  the  majority  of  cases, 
their  arrangement  is  quite  regular,  though  frequently  in- 
clined to  project.  The  alveolar  ridge  usually  describes  a 
broad  arch.  The  excess  in  size,  both  here  and  in  the  teeth, 
seems  to  consist  more  of  gelatine  than  calcareous  phosphate. 
This  description  of  teeth  decay  readily,  and  in  some  in- 
stances appear  to  set  at  defiance  the  resources  of  the  dentist. 
They  are  liable  to  be  attacked  at  almost  every  point,  but 
more  particularly  in  their  indentations  and  approximal  sur- 
faces. 

The  author  is  acquainted  with  a  family,  consisting  ot 
seven  or  eight  members,  most  of  whom  are  adults,  all  hav- 
ing this  sort  of  teeth.  The  most  thorough  attention  has 
been  paid  by  each,  and  yet  all  have  lost  most  of  their  teeth. 
They  are  usually  first  attacked  in  their  approximal  surfaces 
and  indentations,  but  neither  their  labial  faces  nor  most 
prominent  points  are  exempt  from  caries.  No  sooner  than 
its  progress  is  arrested  in  one  place  or  part,  than  it  appears 
in  another.  The  author  has  had  occasion  to  fill  a  single 
tooth  in  as  many  as  four,  five  and  even  six  different  places^ 
15 


1 


218  CHARACTERISTICS   OF   THE   TEETH. 

and  in  this  way,  though  his  efforts  at  the  preservation  of 
a  considerable  number  have  proved  unavailing^  he  has 
been  able  to  save  many  of  them.  But  it  is  not  necessary  to 
particularise  cases.  Every  dentist  has  seen  teeth  of  this  de- 
scription. 

The  corrosive  properties  of  the  fluids  of  the  mouth,  how- 
ever, are  sometimes  so  changed  by  an  amelioration  of  the 
constitution,  that  notwithstanding  the  great  susceptibility 
of  the  teeth  to  disease,  they  are  sometimes  preserved  to  a 
late  period  of  life,  or  until  the  general  health  relapses  into 
its  former,  or  some  other  unfavorable  condition.  This  has 
happened  in  several  instances  that  have  come  under  the  au- 
thor's immediate  observation,  and  it  should  be  borne  in 
mind,  that  the  solvent  qualities  of  these  juices  are  influ- 
enced by  the  state  of  the  constitutional  health. 

Class  Fourth. — Teeth  of  this  class  usually  have  a  white 
chalky  appearance,  are  unequally  developed,  and  of  a  very 
soft  texture.  They  are  easily  acted  upon  by  corrosive 
agents,  and  like  the  teeth  last  noticed,  generally  fall  speedy 
victims  to  disease,  unless  great  care  is  taken  to  secure  their 
preservation. 

Persons  who  have  teeth  such  as  described  in  classes  three 
and  four^  generally  have  what  Laforgue  calls,  lymphatico- 
serous  temperaments.  Their  blood  is  usually  pale,  the 
fluids  of  the  mouth  abundant,  and  for  the  most  part  ex- 
ceedingly viscid.  They  do  not  have  that  white  frothy  ap- 
pearance observable  in  healthy  sanguineus  individuals. 

As  teeth  that  are  neither  too  large  nor  too  small,  and 
that  have  a  close  compact  texture,  and  are  slightly  tinged 
with  yellow,  are  indicative  of  an  innately  good  consti- 
tution, whatever  it  may  be  at  the  present  time,  so  those 
which  are  long,  narrow,  and  faintly  tinged  with  blue,  as 
well  as  those  that  greatly  exceed  the  ordinary  size,  and  that 
are  irregular  in  shape,  and  have  a  rough,  muddy  appear- 
ance, furnish  assurance  of  a  constitution  originally  bad. 
The  first  of  the  latter  descriptions  of  teeth  are  more  fre- 


CHARACTERISTICS   OP  THE  TEETH.  219 

quently  met  with  among  females  than  males,  and  among 
those  of  strumous  habits,  than  those  in  whom  this  diathesis 
does  not  exist. 

Glass  Fifth. — The  teeth  belonging  to  this  class  are  char- 
acterized by  whiteness  and  a  pearly  gloss  of  the  enamel. 
They  are  long,  and  usually  small  in  circumference,  though 
sometimes  well  developed.  They  are  regarded  by  many  as 
denoting  a  tendency  to  phthisis  pulmonalis,  and  are  sup- 
posed by  some  to  be  very  durable,  but  the  author  has  ob- 
served that  individuals  who  have  this  sort  of  teeth,  when 
attacked  by  febrile  or  any  other  form  of  disease  having  a 
tendency  to  alter  the  fluids  of  the  body,  are  very  subject 
to  tooth-ache  and  caries,  and  that  when  this  condition  of 
the  general  system  is  continued  for  a  considerable  length  of 
time,  that  the  teeth,  one  after  another,  in  rapid  succession, 
crumble  to  pieces. 

It  would  seem  from  this  circumstance,  that  the  fluids  of 
the  mouth  of  subjects  of  strumous  habits,  if  free  from  other 
morbid  tendencies,  are  less  prejudical  to  the  teeth  than  they 
are  in  most  other  constitutions,  and  the  author  is  of  the 
opinion  that  it  is  owing  to  this  that  they  are  so  seldom  at- 
tacked by  caries.  M.  Delabarre  believes,  that  caries  super- 
venes to  this  disease,  and  is  a  consequence  of  the  general 
debility  engendered  by  it.  He  says,  however,  that  'Hhe 
patient  generally  dies  before  the  central  ganglion  arrives  at 
that  state  in  which  its  properties  are  changed." 

Now,  this  is  directly  opposed  to  all  observation  on  the 
subject,  for  it  is  well  known,  that  teeth  are  less  afiected  by 
this  disease  than  almost  any  other,  and  it  is  unfortunate  for 
the  doctrine,  which  he  in  another  place  advocates,  that  the 
solid  tissue  of  these  organs  is  softened  by  the  arteries  ceas- 
ing to  supply  it  with  calcareous  materials,  that  he  should 
have  resorted  to  this  argument.  Its  absurdity  is  rendered 
apparent  by  his  own  showing,  and  that,  too,  in  the  para- 
graph succeeding  the  one  in  which  the  argument  is  used. 
He  says,  "whatever  may  be  the  diseased  condition  of  the 


220  CHARACTERISTICS   OF   THE  TEETH. 

teeth,  they  may  be  examined  as  unexceptionable  evidence, 
that  will  inform  us  whether  the  patient  owes  his  present 
state  of  health  to  a  predisposition,  or  whether  having  super- 
vened during  the  course  of  his  life_,  it  depends  on  an  acci- 
dental cause." 

If  the  state  of  the  health,  subsequent  to  dentinification, 
were  capable  of  diminishing  or  increasing  the  density  of 
these  organs  we  could  learn  nothing  by  inspection  of  the 
primordial  constitution.  Nor  would  we,  therefore,  be  able 
to  determine  whether  the  present  state  of  health  was  the 
result  of  constitutional  predisposition,  or  of  some  other 
cause  ;  for,  if  they  were  subject  to  changes,  like  other  parts 
of  the  body,  their  physical  condition  might  be  different  to- 
day from  what  it  was  yesterday,  and  a  diagnosis,  founded 
upon  the  appearance  of  the  teeth,  would  be  nothing  more 
than  mere  vague  conjecture. 

But,  although  Delabarre  is  in  many  things  somewhat  in- 

*»consistent,  many  of  his  views  are  correct,  and  few  men  have 

contributed  more  largely,  by  observation  and  experience, 

to  the  advancement  of  the  science  of  the  teeth,  than  he  has 

done. 

In  speaking  of  persons  who  have  teeth,  which^  though 
beautiful,  from  having  smooth  and  apparently  polished 
surfaces,  present  shades  intermixed  with  a  dirty  white,  he 
says,  they  "have  had  alternations  of  good  and  indifferent 
health  during  the  formation  of  the  enamel.  These  teeth," 
he  continues,  ''ordinarily  have  elongated  crowns,  and  many 
present  marks  of  congenital  atrophy. ' '  Again,  he  observes, 
"teeth  of  this  sort  deceive  us  by  appearing  more  solid  than 
they  are  ;  they  remain  sound  until  about  the  age  of  fourteen 
or  eighteen  ;  then,  at  this  period,  a  certain  number  of  them 
decay,  especially  when  in  infancy  the  subject  was  lymphatic, 
and  continues  to  be  so  in  adolescence.  This  description  of 
teeth  is  freciuently  met  with  among  the  rich  classes,  where 
children  born  feeble,  reach  puberty  only  by  means  of  great 
care,  and,  consequently,  owe  their  existence  only  to  the  un- 
remitting attention  of  their  parents,  and  the  strengthening 


CHARACTERISTICS  OF  THE  TEETH.  221 

regimen  that  the  physician  has  caused  them  constantly  to 
pursue.  Having  reached  the  eighteenth  or  twentieth  year, 
their  health  is  confirmed,  but  the  mucous  membranes  ever 
after  have  a  tendency  to  be  affected  ;  the  redder  color  of  the 
mouth,  more  especially  its  interior,  and  that  of  the  lips,  and 
the  upper  part  of  the  palate,  which,  by  degrees,  discovers 
itself  as  the  subject  gradually  advances  in  existence,  show- 
ing its  ameliorated  condition.  It  is  thus,  that  numerous 
persons,  having  gained  a  sanguineus  temperament,  would 
deceive  us,  if  it  were  not  that  some  marks  of  erosion  are 
seen  on  the  masticating  surfaces  of  the  first  permanent  mo- 
lars, which  informs  us  that  the  present  health  is  the  result 
of  amelioration." 

There  are  other  cases  in  which  the  teeth  are  of  so  in- 
ferior a  quality,  that  they  no  sooner  emerge  from  the  gums 
than  they  are  attacked  and  destroyed  by  caries,  while  the 
subjects  who  possess  them,  are  enabled,  by  skillful  treatment 
to  overcome  the  morbid  constitutional  tendencies,  against 
which,  during  the  earlier  years  of  their  existence,  they  had 
to  contend,  and  eventually,  to  acquire  excellent  health. 
But  in  forming  a  prognosis,  it  is  essential  to  ascertain 
whether  the  general  organic  derangement  which  prevented 
the  teeth  from  being  well  formed_,  and  thus  gave  rise  to 
their  premature  decay,  is  hereditary,  or  whether  it  has  been 
produced  by  some  accidental  cause  subsequent  to  birth. 
The  procurement  of  health  in  the  former  case,  will  be  less 
certain  than  in  the  latter,  for  when  the  original  elements  of 
the  organism  are  bad,  the  attainment  of  a  good  constitution 
is  more  difiicult. 

Persons  of  sanguino-mucous  temperaments,  having  suf- 
fered in  early  childhood  from  febrile  or  inflammatory  dis- 
eases, often  have  their  teeth  affected  with  what  Duval  calls 
the  decorticating  process,  (denudation  of  their  enamel,)  re- 
sulting, no  doubt,  from  the  destruction  of  the  bond  of  union 
between  it  and  the  dentine. 

There  are  other  characteristics  which  the  teeth  present  in 
shape,  size,  density  and  color,  and  from  which  valuable  in- 


222  CHARACTERISTICS   OF   THE  TEETH. 

diictions  might  be  made,  both  with  regard  to  the  innate  con- 
stitution and  the  means  necessary  to  their  own  preserva- 
tion ;  biit  as  the  limits  prescribed  to  this  part  of  our  sub- 
ject will  not  admit  of  their  consideration,  we  shall  conclude 
by  observing,  that  the  appearances  of  these  organs  vary 
almost  to  infinity.  Each  is  indicative  of  the  state  of  the 
general  health  at  the  time  of  their  dentinification,  and  of 
their  own  physical  condition  and  susceptibility  to  disease. 


CHAPTER     THIRD. 

PHYSICAL  CHARACTERISTICS  OF  THE  GUMS. 

Little  can  be  ascertained  concerning  the  innate  constitu- 
tion from  an  inspection  of  the  gums.  Subject  to  the  laws  of 
the  general  economy,  their  appearance  varies  with  the  state 
of  the  general  health  and  the  condition  and  arrangement  of 
the  teeth.  Although  the  proximate  cause  of  disease  in  them 
may  be  regarded  as  local  irritation,  produced  by  depositions 
of  tartar  upon  the  teeth,  or  decayed,  dead,  loose  or  irregu- 
larly arranged  teeth,  or  a  vitiated  state  of  the  fluids  of  the 
mouth,  resulting  from  general  organic  derangement,  or  any 
or  all  of  the  first  mentioned  causes,  their  susceptibility  to 
morbid  impressions  is  influenced  to  a  considerable  extent  by 
the  constitutional  health  ;  and  the  state  of  this  determines, 
too,  the  character  of  the  morbid  effects  produced  upon  them 
by  local  irritants.  For  example,  the  deposition  of  a  small 
quantity  of  tartar  upon  the  teeth,  or  a  dead  or  loose  tooth, 
would  not,  in  a  healthy  person,  of  a  good  constitution,  give 
rise  to  anything  more  than  slight  increased  vascular  action 
in  the  margin  of  the  gums  in  contact  with  it ;  while  in 
a  scorbutic  subject,  it  would  cause  them  to  assume  a  dark 
purple  apj)earance  a  considerable  distance  around,  to  become 
swollen  and  flabby,  to  separate  and  retire  from  the  necks  of 
the  teeth,  or  to  grow  down  upon  their  crowns,  to  ulcerate 
and  bleed  from  the  slightest  injury,  and  to  exhale  a  fetid 
odor.  In  proportion  as  this  disposition  of  body  exists,  their 
liability  to  be  thus  affected  is  increased  ;  and  it  is  only 
among  constitutions  of  this  kind  that  that  peculiar  preter- 
natural morbid  growth,  by  which  the  whole  of  the  crowns 


224  CHARACTERISTICS  OF  THE   GUMS. 

of  the  teeth  sometimes  become  almost  entirely  imbedded  in 
their  substance_,  takes  place. 

But,  notwithstanding  the  dependency  of  the  condition  of 
the  gums  upon  the  state  of  the  constitutional  health,  they 
are  occasionally  affected  with  sponginess  and  inflammation 
in  the  best  temperaments,  and  in  individuals  of  uninter- 
rupted good  health.  The  wrong  position  of  a  tooth,  by 
causing  continued  tension  of  the  gums  investing  its  alveo- 
lus, sooner  or  later  gives  rise  to  a  sort  of  chronic  inflamma- 
tion in  them  and  the  alveolo-dental  periosteum,  and  gradual 
wasting  of  their  substance  about  the  mal-placed  organ. 
Tooth-ache,  too,  from  whatever  cause,  often  produces  the  same 
effects,  and  the  accumulation  of  salivary  calculus  upon  the 
teeth,  however  small  the  quantity,  is  likewise  prejudicial. 

All  of  these  may  occur  independently  of  the  state  of  the 
general  health.  A  bad  arrangement  of  the  best  constituted 
teeth,  and  tooth-ache  may  be  produced  by  a  multitude  of 
accidental  causes,  independently  of  the  functional  operations 
of  other  parts  of  the  body. 

While,  therefore,  the  appearance  and  physical  condition 
of  this  peculiar  and  highly  vascular  structure  are  influenced 
in  a  great  degree  by  habit  of  body_,  they  are  not  diagnostics 
that  always,,  and  with  unerring  certainty,  indicate  the 
pathognomic  state  of  the  general  system.  It  can,  however, 
in  by  far  the  larger  number  of  cases,  where  the  gums  are 
in  an  unhealthy  condition,  be  readily  ascertained  whether 
the  disease  is  altogether  the  result  of  local  irritation,  or 
whether  it  is  favored  by  constitutional  tendencies. 

In  childhood,  or  during  adolescence,  when  the  formative 
forces  of  the  body  are  all  in  active  operation,  and  the  nervous 
susceptibilities  of  every  part  of  the  organism  highly  acute, 
the  sympathies  between  the  gums  and  other  parts  of  the 
system,  and  particularly  the  stomach,  are,  perhaps,  greater 
than  at  any  other  period  of  life.  The  general  health,  too, 
at  this  time,  is  more  fluctuating,  and  with  all  the  changes 
this  undergoes,  the  appearances  of  the  gums  vary.  More- 
over, there  are  operations  carried  on  beneath  and  within 


CHARACTERISTICS  OF  THE   GUMS.  225 

their  substance,  which  are  almost  constantly  altering  their 
appearance  and  physical  condition — and  which,  being  addi- 
tionally influenced  by  various  states  of  health  and  habits  of 
body,  it  may  readily  be  conceived  that  those  met  with  in 
one  case,  might  be  looked  for  in  vain  in  another. 

Having  arrived  at  that  age  when  all  the  organs  of  the 
body  are  in  full  vigor  of  maturity,  and  not  under  the  debili- 
tating influences  to  which  they  are  subject  during  the 
earlier  periods  of  life,  the  gums  participate  in  the  happy 
change,  and  as  a  consequence,  present  less  variety  in  their 
characteristics.  The  general  irritability  of  the  system  is 
not  now  so  great,  the  gums  are  less  susceptible  to  the  action 
of  irritating  agents^  and  as  a  consequence,  less  frequently 
affected  with  disease  ;  but  as  age  advances,  and  the  vital 
energies  begin  to  diminish,  the  latent  tendencies  of  the 
body  are  re-awakened,  and  they  are  again  easily  excited  to 
morbid  action. 

In  the  most  perfect  constitutions,  and  during  adolescence, 
they  present  the  following  appearances.  They  have  a  pale 
rose-red  color,  a  firm  consistence,  a  slightly  uneven  surface  ; 
their  margins  form  along  the  outer  surfaces  of  the  dental 
circle  beautiful  and  regular  festoons,  and  the  mucous  mem- 
brane, here,  as  well  as  in  other  parts  of  the  mouth,  has  a 
fresh,  lively,  roseate  hue. 

The  time  for  the  moulting  of  a  primary  tooth  is  announced 
some  weeks  before  it  takes  place,  by  increased  redness  and 
slight  tumefaction  of  the  edges  and  apices  of  the  gums  sur- 
rounding it.  The  eruption  of  a  tooth,  whether  of  the  first 
or  second  set,  is  also  preceded  by  similar  phenomena  in  the 
gums  through  which  it  is  forcing  its  way,  and  these  will  be 
more  marked  as  the  condition  of  the  system  is  unhealthy,, 
or  as  the  habit  of  body  is  bad. 

If  the  health  of  the  subject  continues  good,  and  the  teeth 
are  well  arranged,  and  the  necessary  attention  to  their 
cleanliness  be  strictly  observed,  the  characteristics  just 
enumerated  will  be  preserved  through  life,  except  there 
will  be  a  slight  diminution  of  color  in  them,  after  the  age 


226  CHARACTERISTICS   OF   THE   GUMS. 

of  puberty  until  that  of  the  climacteric  period  of  life_,  when 
they  will  again  assume  a  somewhat  redder  appearance. 
But  if  the  health  of  the  subject  becomes  impaired_,  or  the 
teeth  be  not  regularly  arranged,  or  wear  off,  or  are  not 
kept  free  from  all  lodgments  of  extraneous  matter,  their 
edges,  and  particularly  their  apices,  will  inflame,  swell, 
and  become  more  than  ordinarily  sensitive. 

The  gradual  wasting  or  destruction  of  the  margins  of  the 
gums  around  the  necks  of  the  teeth,  which  sometimes  takes 
place  in  the  best  constitutions,  and  is  supposed  by  some  to 
be  the  result  of  general  atrophy,  is  ascribable,  we  have  no 
doubt,  to  some  one  or  other  of  these  causes — favored,  per- 
haps, by  a  diminution  of  vitality  in  the  teeth^  whereby  they 
are  rendered  more  obnoxious  to  the  more  sensitive  and  vas- 
cular parts  within  which  their  roots  are  situated.  That 
these  are  the  causes  of  the  affection,  (for  it  is  evidently  the 
result  of  diseased  action  in  the  gums,)  is  rendered  more  than 
probable,  by  the  fact,  that  it  rarely  occurs  with  those  who, 
from  early  childhood,  have  been  in  the  regular  and  constant 
habit  of  thoroughly  cleansing  their  teeth  from  four  to  five 
times  a  day. 

Mr.  Bell,  however,  while  he  thinks  it  may  occasionally  be 
an  "indication  of  a  sort  of  premature  old  age,"  does  not  be- 
lieve it  can  "always  be  thus  accounted  for,  as  it  is  sometimes 
seen  in  young  persons,"  and  "doubtless  arises,"  he  says, 
"from  the  same  cause  as  those  presently  to  be  considered," 
(alluding  to  what  he  afterwards  says  upon  the  same  subject,) 
"as  originating  a  similar  loss  of  substance  in  these  parts, 
when  attended  with  more  or  less  of  diseased  action."  We 
cannot,  for  reasons  already  assigned,  concur  with  him  in 
opinion  that  it  "occasionally  takes  place  without  any 
obvious  local  or  constitutional  morbid  action." 

Although  possessed  of  a  good  constitution,  a  person  may, 
by  intemperance,  debauchery,  or  long  privation  of  the  ne- 
cessary comforts  of  life,  or  protracted  febrile  or  other  severe 
kinds  of  disease,  have  his  assimilative  and  all  the  other 
organs  of  the  body  so  enervated  as  to   render  every  part  of 


CHARACTERISTICS   OF  THE   GUMS.  227 

the  system  liiglily  susceptible  to  morbid  impressions  of 
every  sort,  but  still,  this  general  functional  derangement 
rarely  predisposes  the  structure  now  under  consideration,  to 
any  of  the  more  malignant  forms  of  disease  occasionally 
known  to  attack  it  in  subjects  possessed  of  less  favorable 
innate  constitutions.  The  margins  of  the  gums  may  in- 
flame, become  turgid,  ulcerate,  and  recede  from  the  necks 
of  the  teeth,  and  the  whole  of  their  substance  be  involved 
in  an  unhealthy  condition,  but  they  will  seldom  be  attacked 
with  scirrhous  or  fungous  tumors,  or  bad  conditioned  ulcers, 
or  affected  with  preternatural  morbid  growths,  and  in  the 
treatment  of  their  diseases,  we  can  always  form  a  more 
favorable  prognosis  in  persons  of  this  description,  than 
those  coming  into  the  world  with  some  specific  morbid 
tendency. 

But,  the  occurrence  of  severe  constitutional  disease,  even 
in  these  subjects,  is  followed  by  increased  irritability  of  the 
gums,  so  that  the  slightest  cause  of  local  irritation  gives 
rise  to  an  afflux  of  blood  to  and  stasis  of  this  fluid  in  their 
capillaries. 

The  teeth  of  persons  thus  happily  constituted,  are  en- 
dowed with  characteristics,  such  as  have  been  represented 
as  belonging  to  those  of  the  best  quality.  They  are  of  a 
medium  size,  both  in  length  and  volume,  white,  compact  in 
their  structure^  generally  well  arranged,  and  seldom  affect- 
ed,,with  caries. 

Another  constitution  is  observed,  in  which  the  gums, 
though  partaking  somewhat  of  the  characteristics  just  de- 
scribed, differ  from  them  in  some  particulars.  Their  color 
is  of  a  deeper  vermilion  ;  their  edges  rather  thicker,  their 
structure  less  firm,  and  their  surface  not  so  rough,  but  more 
humid.  The  mucous  membrane  has  a  more  lively  and  ani- 
mated appearance.  They  are  more  sensitive  and  more  sus- 
ceptible to  the  action  of  local  irritants,  with  morbid  tenden- 
cies more  increased  by  geneal  organic  derangement,  than 
when  possessed  of  the  appearances  first  mentioned. 

When  in  a  morbid  condition_,  the  disease,  though  easily 


228  CHARACTERISTICS   OF   THE   GUMS. 

cured  by  jn'oper  treatment,  is,  nevertlieless,  more  obsti- 
nate, and  when  favored  by  constitutional  derangement,  as- 
sumes a  still  more  aggravated  form.  Their  predisi)osition 
to  disease  is  so  much  increased  by  long  continued  disturb- 
ance of  the  general  system,  and  especially  during  youth, 
and  by  febrile  or  inflammatory  affections,  that  not  only  their 
margins,  but  their  whole  substance,  sometimes  becomes  in- 
volved in  inflammation  and  sponginess,  followed  by  ulcera- 
tion of  their  edges,  and  recession  from  the  necks  of  the 
teeth,  which,  in  consequence^  loosen,  and  often  drop  out. 
But  gums  of  this  kind,  like  those  first  described,  seldom 
grow  down  upon  the  crowns  of  the  teeth.  Neither  are  they 
very  liable  to  be  attacked  with  scirrhous  or  fungous  tu- 
mors, or  any  form  of  disease  resulting  in  sanious  or  other 
malignant  conditioned  ulcers.  Indeed,  with  diseases  of  this 
kind,  they  are  not^  perhaps,  ever  affected,  except  in  those 
cases  where  every  part  of  the  body  has  become  exceedingly 
depraved  by  intemperance^  debauchery,  or  some  other  cause. 

The  teeth  of  those  whose  gums  are  of  this  description,  if 
well  arranged  and  kept  constantly  clean — and,  if  the  secre- 
tions of  the  mouth  be  not  vitiated  by  general  disease,  will, 
in  most  cases,  remain  healthy  through  life. 

It  is  only  among  sanguineus  persons  that  this  description 
of  gums  is  met  with,  and  the  teeth  of  subjects  of  this  kind 
are  generally  of  excellent  quality,  and  though  more  liable 
to  be  attacked  by  caries  than  those  first  noticed,  they  are 
seldom  affected  with  it. 

In  sanguino-serous  and  strumous  subjects,  the  gums  are 
pale,  and  though  their  margins  are  thin  and  well  festooned, 
often  exude,  after  the  twenty-fifth  or  thirtieth  year,  a  small 
quantity  of  muco-purulent  matter,  which^  on  pressure,  oozes 
from  between  them  and  the  necks  of  the  teeth.  Their  tex- 
ture is  usually  firm,  and  they  are  not  very  liable  to  become 
turgid.  They  often  remain  in  this  condition  to  a  late 
period  of  life,  without  undergoing  any  very  perceptible 
change.     Their  connection  with  the  necks  of  the  teeth  and 


CHARACTERISTICS   OF   THE  GUMS.  229 

alveolar  processes  appears  weak,  but  tliey  rarely  separate 
from  them. 

In  remarking  upon  individuals  having  such  constitutions, 
M.  Delabarre  says,  that  if  they  ''abuse  their  physical  pow- 
ers," by  an  injudicious  regimen,  or  too  much  study,  they 
become  enervated  and  "^are  subject  to  chronic  sanguineus 
obstructions  of  the  capillaries  of  the  lungs,  and  to  profuse 
hemorrhages."  Dyspepsia  and  diseases  in  which  the  primse 
viae  generally  is  more  or  less  involved,  and  chronic  hepa- 
titis, are  not  unfrequent,  and  are  indicated  by  increased  ir- 
ritability, and  sometimes,  a  pale  yellowish  appearance  of 
the  gums.  In  jaundice,  the  yellow  serosity  of  the  blood  is 
very  apparent  in  the  capillaries  of  this  structure. 

These  constitutions  are  more  common  to  females  than 
males,  to  the  rich  than  the  poor,  and  to  persons  of  sedenta- 
ry habits  than  to  those  who  use  invigorating  exercise.  If 
at  any  time  during  life  the  health  is  ameliorated,  the  gums 
assume  a  fresher  and  redder  appearance,  and  the  exudation 
of  muco-purulent  matter  from  between  them  and  the  necks 
of  the  teeth  ceases. 

In  mucous  dispositions,  the  gums  have  a  smooth,  shining 
appearance,  and  are  rather  more  highly  colored  than  the 
preceding.  Their  margins^  also,  are  thicker,  more  flabby, 
and  not  so  deeply  festooned  ;  they  are  more  irritable,  and, 
consequently,  more  susceptible  to  morbid  impressions. 

If,  to  this  disposition,  there  be  combined  a  scorbutic  or 
scr'&ftilous  tendency,  the  gums  during  early  childhood,  in 
subjects  which,  from  scanty  and  unwholesome  diet,  have 
become  greatly  debilitated,  are  liable,  besides  the  ordinary 
forms  of  disease  to  another,  characterized  by  their  separa- 
tion from,  and  exfoliation  of,  the  alveolar  processes — accom- 
panied by  a  constant  discharge  of  sanies.  This  form  of 
disease,  however,  though  peculiar  to  childhood,  and  wholly 
confined  to  the  indigent,  is  by  no  means  common. 

These  constitutions  are  rarely  met  with,  except  among 
persons  who  live  in  cellars^  and  damp  and  closely  confined 
rooms  in  large  cities,  and  in  low,  damp,  and  sickly  districts 


230  CHARACTERISTICS   OF   THE  GUMS. 

of  country.  The  mucous  membrane  in  subjects  of  this  kind 
is  exceedingly  irritable,  and  secretes  a  large  quantity  of 
mucus. 

In  alluding  to  this  species  of  disposition,  M.  Delabarre 
says,  "in  children,  the  skin  is  ordinarily  white  and  tender; 
nevertheless,  it  is  sometimes  brown  and  wrinkled.  They 
are  usually  fragile  and  weak ;  their  blood  is  pale,  their  nu- 
trition is  imperfectly  effected.  In  females,  the  vertebral 
column  is  disposed  to  curve  about  the  age  of  puberty,  be- 
cause," says  he,  '^at  this  period,  the  vital  energies  are 
principally  directed  towards  the  uterus,  and^  in  conse- 
quence, although  so  very  necessary  in  the  osseous  system, 
they  aj)pear  to  be  weak, 

''The  number  of  observations  that  I  have  collected  dur- 
ing my  practice  in  the  city,  and  in  several  public  institu- 
tions, have  confirmed  me  in  the  opinion,  that  it  is  in  this 
constitution,  especially,  (alluding  to  the  mucous,)  that  the 
children  of  whom  we  have  just  spoken,  are  met  with.  The 
organic  life  in  them  has  so  little  energy,  that  a  local  cause 
on  a  certain  point,  operates  with  greater  activity  than  it 
would  otherwise  do,  sensibly  diminishing  the  assimilative 
force  of  almost  all  the  others.  It  is  also  probable,  that  the 
development  of  ganglionic  obstructions  during  dentition, 
are,  many  times,  owing  to  the  diminution  of  the  sensibility 
in  the  lymphatics. 

"We  may  also  remark,"  says  he,  "that,,  their  skin  being 
very  susceptible,  the  sympathy  established  between  it  and 
the  mucous  membranes,  renders  individuals  of  this  kind 
very  liable  to  contract  rheums,  and  gastric  and  intestinal 
affections  ;  they  are,  likewise,  subject  to  easy  night  sweats, 
and  vomitings  of  a  seromucous  fluid,"  etc. 

Persons  even  thus  unhappily  constituted,  do,  sometimes, 
by  change  of  residence  and  judicious  regimen,  acquire 
tolerably  good  constitutions.  Little  advantage,  however,  is 
derived  from  these,  unless  tliey  are  had  recourse  to  before 
the  twenty-fifth  or  thirtieth  year  of  age,  though  they  may 
prove  beneficial  at  a  much  later  period. 


CHARACTERISTICS   OF   THE   GUMS.  231 

The  gums,  in  scorbutic  persons,  have  a  reddish  brown 
color ;  their  margins  are  imperfectly  festooned^  and  thick ; 
their  structure  rather  disposed  to  become  turgid,  and  ever 
ready,  on  the  presence  of  the  slightest  cause  of  local  irrita- 
tion, to  take  on  a  morbid  action.  When  thus  excited,  the 
blood  accumulates  in  their  vessels — where^  from  its  highly 
carbonized  state,  it  gives  to  the  gums  a  dark,  purple,  or 
broAvn  appearance;  they  swell,  and  become  spongy  and 
flabby,  and  bleed  from  the  slightest  touch.  To  these  symp- 
toms, supervene  the  exhalation  of  a  fetid  odor,  the  destruc- 
tion of  the  bond  of  union  between  them  and  the  necks  of 
the  teeth,  suppuration  and  recession  of  their  margins  from 
the  same — gradual  wasting  of  the  alveolar  cavities,  loosen- 
ing, and  not  unfrequently,  the  loss  of  several,  or  the 
whole  of  the  teeth.  These  are  the  most  common  results, 
but,  sometimes,  they  take  on  other  and  more  aggravated 
forms  of  diseased  action.  Preternatural  prurient  growths  of 
their  substance,  fungous  and  scirrhous  tumors,  ichorous  and 
other  malignant,  ill-conditioned  ulcers,  etc. 

The  occurrence  of  alveolar  abscess  in  dispositions  of  this 
kind  is  often  followed  by  necrosis  and  exfoliation  of  portions 
of  the  maxillary  bone,  and  the  effects  which  result  to  the  gums 
are  always  more  pernicious  than  in  habits  less  depraved. 

The  development  of  the  morbid  changes  which  take  place 
in  this  structure,,  even  in  subjects  of  this  kind,  while  the 
character  of  the  disease  is  influenced,  if  not  determined,  by 
a  specific  constitutional  tendency,  is,  nevertheless,  referable 
to  local  irritation  as  the  immediate  or  proximate  cause,  and, 
were  this  the  proper  place,  we  could  cite  numerous  cases 
tending  to  establish  the  truth  of  this  opinion. 

In  scrofulous  habits,  the  gums  have  a  pale  bluish  appear- 
ance, and  when  subjected  to  local  irritation,  they  become 
flabby,  exhale  a  nauseating  odor,  detach  themselves  from 
the  necks  of  the  teeth,  and  their  apices  grow  down  between 
these  oi'gans.  The  blood  circulates  in  them  languidly,  and 
debility  seems  to  pervade  their  whole  substance.  They  are 
exceedingly  irritable,  and  not  unfrequently  take  on  aggra- 


232  CHARACTERISTICS   OF   THE   GUMS. 

vated  forms  of  disease,  and^  as  often  happens  to  this,  as  well 
as  to  the  preceding  hahit,  there  are  combined  tendencies 
which  favor  the  production  of  ill-conditioned  tumors  and 
ulcers. 

The  indications  furnished  by  the  gums  during  the  exist- 
ence of  a  mercurial  diathesis  of  the  system,  are,  morbid  sen- 
sibility, increased  vascular  and  glandular  action,  foulness, 
bleeding  from  the  most  trifling  injuries,  pale  bluish  appear- 
ance of  their  substance,  turgidity  of  their  apices  and  slough- 
ing. The  effects,  however,  resulting  to  these  parts  from  the 
use  of  mercury  differ  in  different  individuals  according  to 
the  general  constitutional  susceptibility,  the  quantity  taken 
into  the  system,  and  the  length  of  time  its  use  has  been 
continued.  In  persons  of  very  irritable  habits,  a  single 
dose  will  sometimes  produce  ptyalism,  and  so  increase  the 
susceptibility  of  the  gums,  that  the  secretions  of  the  mouth, 
in  their  altered  state,  will  at  once  rouse  up  a  morbid  action 
in  them. 

The  effects  of  a  mercurial  diathesis  upon  these  parts,  is 
not  unfrequently  so  great  as  to  result  in  the  loss  of  the 
whole  of  the  teeth.  But  with  these  effects  both  the  dental 
and  medical  practitioner  are  too  familiar  to  require  any 
further  description. 

Finally,  we  would  observe,  that  the  indications  of  the 
several  characteristics  to  which  we  have  now  briefly  alluded, 
may  not  be  correct  in  every  particular,  and  there  are  others 
which  we  have  not  mentioned  ;  yet  we  think  they  will  gen- 
erally be  found  true.  As  a  general  rule,  persons  of  a  full 
habit,  though  possessed  of  mixed  temperaments  and  in  the 
enjoyment  of  what  is  usually  called  good  health,  have  gums 
well  colored,  with  rather  thick  margins,  and  very  suscepti- 
ble to  local  irritation.  With  this  description  of  individ- 
uals, inflammation,  turgidity,  and  suppuration  of  the  gums 
are  very  common.  To  prevent  these  effects,  constant  atten- 
tion to  the  cleanliness  of  the  teeth  is  indispensable. 

Professor  Schill  says,  the  "gum  is  pale  in  chlorosis  and 
anaemia  ;  of  a  purple  red  color  before  an  active  hemorrhoi- 


CHARACTERISTICS   OF   THE   GUMS.  233 

dal  discliarge,  and  in  cases  of  dysmenorrlicea  ;  of  a  dark  red 
color,  spongy,  and  bleeding  readily  in  scurvy  and  diabetes 
mellitus,  and  after  tlie  use  of  mercury.  Spongy  growths 
indicate  caries  of  tbe  subjacent  bone."* 

Regular  periodical  bleedings  of  the  gums  in  dysmenor- 
rlicea, and  particularly  in  scorbutic  and  mucous  subjects, 
are  not  unfrequent,  nor  in  any  case  where  they  are  in  a 
turgid  condition. 

Spongy  growth  of  the  gums  in  scorbutic  and  scrofulous 
persons,  often  result  from  irritation  produced  by  decayed 
teeth,  and  are  not,  therefore,  always  to  be  regarded  as  an 
indication  of  caries  of  the  subjacent  bone. 

Dr.  T.  Thompsonof  London,  says,  that  the  reflected  mar- 
gin of  the  gums  of  a  large  majority  of  phthisical  patients, 
is  deeper  in  color,  usually  presenting  a  vermilion  tint,  than 
the  other  portions. f 

Mr.  George  Waite  says,  "a  change  of  residence  to  a  damp 
climate  will  often  rouse  up  in  the  gums  a  great  degree  of 
vascularity.  In  the  damp  places  of  England  and  Ireland 
the  appearances  which  the  gums  present  are  of  a  turgid  and 
vascular  nature.  In  the  damp  countries  of  France,  these 
conditions  of  the  gums  run  a  much  greater  length  from  the 
circumstance  of  the  difference  in  the  constitutions  of  the  two 
nations.  In  the  damps  of  Germany  and  Switzerland,  per- 
sons also  lose  their  teeth  early  in  life,  the  climate  engenders 
malaria  and  low  fevers,  enfeebles  the  power  of  digestion, 
and  brings  on  rheumatic  affections  with  languor  and  general 
constitutional  debility." 

Of  the  correctness  of  Mr.  Waite' s  observations  there  can 
be  no  question,  and  they  go  to  establish  what  has  been  said 
in  regard  to  the  predisposing  cause  of  disease  in  the  gums — 
namely,  that  the  enervation  of  the  vital  powers  of  the  body, 
from  whatever  cause  produced,  increases  their  susceptibili- 
ty to  morbid  impressions. 

*  Outlines  of  Pathological  Semeiology,  page  168,  of  the  Select  Medical  Library 
edition, 
t  Clinical  Lectures  on  Pulmonary  Consumption,  p.  117. 

16 


CHAPTER    FOURTH. 
PHYSICAL  CHARACTERISTICS  OF   SALIVARY  CALCULUS. 

The  color,  consistence,  and  quantity  of  saHvary  calculus 
or  tartar^  as  it  is  most  commonly  called,  varies  in  diiferent 
temi)eraments,  and  upon  all  of  wLicli,  the  state  of  the  gen- 
eral health  exercises  considerable  influence.  The  character- 
istics of  this  substance,  therefore,  furnish  diagnoses,  impor- 
tant both  to  the  physician  and  dentist.  Their  indications 
are  in  many  cases  less  equivocal  than  the  appearances  of 
any  other  part  of  the  mouth  ;  but,  like  those  of  the  gums, 
should  not  perhaps,  be  alone  relied  upon.  It  is  necessary 
to  interrogate  every  part  from  which  information  can  be  de- 
rived concerning  the  pathological  condition  of  the  several 
organs  of  the  body. 

Salivary  calculus  is  composed  of  earthy  salts  and  animal 
matter.  Phosphate  of  lime  and  fibrina,  or  cartilage,  are  its 
principal  ingredients  ;  a  small  quantity  of  animal  fat,  how- 
ever, enters  into  its  composition,  and  the  relative  proportions 
of  its  constituents  vary  according  as  it  is  hard  or  soft,  or  as  the 
temperament  of  the  individual  from  whose  mouth  it  is  taken, 
is  favorable  or  unfavorable  to  health ;  hence  it  is,  that  the 
analyses  that  have  been  made  of  it  by  different  chemists,  dif- 
fer.    No  two  give  the  same  result. 

The  black,  dry  tartar,  deposited  around  the  necks  of  the 
teeth  of  such  only  as  have  good  constitutions,  is  never  in 
large  quantity — is  dissolved  in  muriatic  acid  with  difficulty, 
while  the  dry  light  brown  tartar  found  upon  the  teeth  of 
bilious  persons,  dissolves  more  readily  in  it;  but  the  soft 
white  tartar,  found  upon  the  teeth  of  individuals  of  mucous 


CHARACTERISTICS   OF  SALIVARY  CALCULUS.  235 

temperaments,  is  scarcely  at  all  soluble  in  tlie  acids,  but  is 
readily  dissolved  in  tbe  alkalies.* 

All  persons  are  subject  to  salivary  calculus,  but  not  alike; 
it  collects  on  the  teetb  of  some  in  larger  quantities  than  on 
those  of  others,  and  its  chemical  and  physical  characteristics 
are  exceedingly  variable.  It  is,  sometimes,  almost  wholly 
composed  of  calcareous  ingredients  ;  at  other  times,  these 
constitute  but  about  one-half,  or  little  more  than  one-half  of 
its  substance — the  remainder  being  made  up  of  animal  mat- 
ter. Nor  is  its  color  more  uniform.  Sometimes  it  is  black, 
at  other  times  it  is  of  a  dark,  pale,  or  yellowish  brown,  and 
in  some  instances  it  is  nearly  white.  It  also  differs  in 
density.  In  the  mouths  of  some  it  has  a  solidity  of  texture 
nearly  equal  to  that  of  the  teeth  themselves,  in  others,  it  is 
so  soft  that  it  can  be  scraped  from  the  teeth  with  the  thumb 
or  finger  nail.  The  black  kind  is  the  hardest,  the  white 
the  softest,  and  its  density  is  increased  or  diminished  as  it 
approaches  the  one  or  the  other  of  these  colors. 

Salivary  calculus  collects  in  very  small  quantities  on 
the  teeth  of  persons  possessed  of  the  most  j^erfect  constitu- 
tion, and,  even  on  these  it  is  seldom  found,  except  on  the 
inner  surfaces  of  the  lower  incisors  next  the  gums.  It  is 
then  black,  or  of  a  dark  brown;  very  dry,  and  almost  as 
hard  as  the  teeth,  to  which  it  adheres  with  great  tenacity. 

It  rarely  hai^pens  that  any  unpleasant  effects  are  produced 
by  the  presence  of  this  kind  of  tartar  upon  the  teeth.  The 
general  health  is  never  affected  by  it,  and  the  only  local 
injury  that  results  from  it,  is  slight  turgidity  of  the  edge  of 
the  gums  in  immediate  contact  with  it. 

The  indications,  therefore,  of  this  description  of  tartar^  are 
favorable^  botli  with  regard  to  the  teeth,  gums  and  organ- 
ism generally.  The  teeth  upon  which  it  is  found  are  of  an 
excellent  quality  and  rarely  affected  by  caries.  They  have 
the  characteristics  represented  as  belonging  to  the  best  kind 

*  See  M.  Delabarre's  Traite  de  la  Seconde  Dentition. 


236  CHARACTERISTICS   OF   SALIVARY   CALCULUS. 

and  teeth  of  this  description  are  only  found  among  persons 
having  good  innate  constitutions. 

There  is  another  kind  of  black  tartar,  differing  from  this 
in  many  particulars.  It  is  found  in  the  mouths  of  those 
having  good  innate  constitutions,  but  whose  physical  powers 
have  been  enervated  by  privation  of  the  necessary  com- 
forts of  life,  or  disease,  or  intemperence  and  debauchery, 
and  most  frequently  by  the  last.  It  is  found  in  large 
quantities  on  the  teeth  opposite  the  mouths  of  the  salivary 
ducts ;  it  is  exceedingly  hard,  and  agglutinated  so  firmly  to 
the  organs,  that  it  is  removed  with  great  difficulty ;  it  is  very 
black;  has  a  rough  and  uneven  surface,  is  covered  with  a 
glairy^,  viscid,  and  almost  insufferably  offensive  mucus. 

The  presence  of  this  kind  of  salivary  calculus  is  attended 
with  very  hurtful  consequences,  not  only  to  the  gums,  alve- 
olar processes  and  teeth,  but  also  to  the  general  health.  It 
causes  the  gums  to  inflame,  swell,  suppurate  and  recede 
from  the  teeth — the  alveoli  to  waste,  and  the  teeth  to  loosen 
and  frequently  to  drop  out.  The  secretions  of  the  mouth 
are  also  vitiated  by  it,  and  rendered  unfit  to  be  taken  into 
the  stomach.  Hence,  as  long  as  it  is  permitted  to  remain 
on  the  teeth,  neither  the  skill  of  the  physician,  nor  the  best 
regulated  regimen,  though  they  may  afford  partial  and 
temporary  relief,  will  fully  restore  to  the  system  its  healthy 
functions. 

As  this  kind  of  tartar  is  seldom  if  ever  met  with  except  in 
excellent  constitutions,  the  teeth  on  which  it  is  deposited  are 
generally  sound,  but  they  are  often  caused  by  the  disease 
which  is  produced  in  the  gums  and  alveoli,  to  loosen  and 
drop  out. 

The  dark  brown  tartar  is  not  as  hard  as  either  of  the  de- 
scriptions of  black.  It  sometimes  collects  in  tolerably  large 
quantities  on  the  lower  front  teeth,  and  on  the  first  and 
second  superior  molars  ;  it  is  also  often  found  on  all  the 
teeth,  though  not  in  as  great  abundance  as  on  these.  It 
does  not  adhere  with  as  much  tenacity  as  either  of  the  pre- 
ceding kinds,  and  can  be  more  easily  detached  from  them. 


CHARACTERISTICS   OF   SALIVARY   CALCULUS.  237 

It  exhales  a  more  fetid  odor  than  the  first  variety,  but  is 
less  offensive  than  the  second. 

The  persons  most  subject  to  this  kind  of  tartar,  are  of 
mixed  temperaments — the  sanguineus,  however,  almost  al- 
ways j)redominating.  They  may  be  denominated  sanguino- 
serous  and  bilious.  Their  physical  organization,  though 
not  the  strongest  and  most  perfect,  may,  nevertheless,  be 
considered  very  good.  But,  being  more  susceptible  to  mor- 
bid im]3ressions,  their  general  health  is  less  uniform,  and 
more  liable  to  impairment  than  those  possessed  of  the  most 
perfect  constitutions. 

The  effects  arising  from  accumulations  of  this  description 
of  salivary  calculus,  both  local  and  constitutional,  are  less 
hurtful  than  the  variety  last  noticed,  but  like  that^  it  causes 
the  gums  to  inflame,  swell,  suppurate,  and  to  retire  from  and 
expose  the  necks  of  the  teeth,  the  alveoli  to  waste,  the  teeth 
to  loosen  and  sometimes  to  drop  out.  It  also  gives  rise  to 
a  vitiated  condition  of  the  fluids  of  the  mouth. 

Salivary  calculus  of  a  light  or  pale  yellowish  brown  color, 
is  of  a  much  softer  consistence  than  the  darker  varieties, 
and  is  seldom  found  upon  the  teeth,  except  of  persons  of 
bilious  temperaments,  or  those  in  whom  this  predominates. 
It  has  a  rough  and  for  the  most  part,  a  dry  surface ;  it  is 
found  in  large  quantities  opposite  the  mouths  of  the  salivary 
ducts,  and  sometimes  every  tooth  in  the  mouth  is  completely 
imbedded  in  it.  It  contains  less  of  the  earthy  salts  and 
more  of  the  fibrina  and  animal  fat  than  any  of  the  foregoing 
descriptions,  and  from  the  quantity  of  vitiated  mucus  in  and 
adhering  to  it,  has  an  exceedingly  offensive  smell.  It  is, 
sometimes,  though  not  always,  so  soft  that  it  may  be 
crumbled  between  the  thumb  and  finger. 

Inflammation^  turgescence  and  suppuration  of  the  gums, 
inflammation  of  the  alveolo-dental  periosteum,  the  destruc- 
tion of  the  sockets  and  loss  of  the  teeth,  and  an  altered  con- 
dition of  the  fluids  of  the  mouth,  are  among  the  local  effects 
produced  by  the  long  continued  presence  of  large  collections 
of  this  variety  of  tartar.     The  constitutional  effects  are  not 


238  CHARACTERISTICS   OF   SALIVARY  CALCULUS. 

much  less  pernicious.  Indigestion  and  general  derange- 
ment of  all  the  assimilative  functions  are  among  the  most 
common.  When  the  deposit  is  not  large,  inflammation  and 
sponginess  of  such  parts  of  the  gums  as  are  in  immediate 
contact  with  it,  and  fetid  hreath,  are  the  principal  of  the 
unpleasant  effects  produced  by  it. 

White  tartar  rarely  collects  in  very  large  quantities,  and 
though  most  abundant  on  the  outer  surfaces  of  the  first  and 
second  superior  molars,  and  the  inner  surfaces  of  the  lower 
incisors,  it  is  nevertheless  frequently  found  on  all  the  teeth. 
Its  calcareous  ingredients  are  less  abundant  than  those  of 
any  of  the  preceding  descriptions.  Fibrina,  animal  fat, 
and  mucus,  constitute  by  far  the  larger  portion  of  its  sub- 
stance. It  is  very  soft,  seldom  exceeding  in  consistence 
common  cheese  curd,  to  which  in  appearance  it  bears  con- 
siderable resemblance.  Although  it  exerts  but  little  me- 
chanical irritation  upon  the  gums,  it  keeps  up  a  constant 
morbid  action  in  them.  Its  effects,  however,  upon  the 
teeth,  are  by  far  more  deleterious  than  any  other  descrip- 
tion of  tartar.  It  corrodes  the  enamel,  and  causes  rapid 
decay  of  the  organs.  The  fluids  of  the  mouth  are  also 
vitiated  by  it. 

It  is  only  upon  the  teeth  of  persons  of  mucous  habits,  or 
those  who  have  suffered  from  diseases  of  the  mucous  mem- 
branes, or  those  in  whom  these  tissues  have  been  more  or 
less  involved,  that  this  kind  of  tartar  accumulates. 

There  is  one  other  kind  of  tartar  described  by  dental 
writers.  It  is  of  a  dark  green  color,  and  is  seen  more  fre- 
quently on  the  anterior  surfaces  of  the  upper  teeth  occupy- 
ing the  front  part  of  the  mouth,  than  on  any  of  the  others. 
It  resembles  more  that  of  a  stain  on  the  enamel  than  sali- 
vary calculus.  Children  and  young  persons  are  more 
subject  to  it  than  adults^  though  it  is  occasionally  observed 
on  the  teeth  of  the  latter.  It  is  exceedingly  acrid,  and  has 
the  effect  of  decomposing  the  enamel ;  the  margins  of  the 
gums  around  the  teeth  having  it  on  them,  are  inflamed, 
and  the  sanguineus  capillaries  of  their  whole  substance 
appear  to  be  distended  and  more  than  ordinarily  languid. 


1 


CHARACTERISTICS   OF   SALIVARY   CALCULUS.  239 

This  kind  of  discoloration  of  the  enamel  is  indicative  of 
an  irritable  condition  of  the  mucous  membranes  and  viscid- 
ity of  the  fluids  of  the  mouth.  Sour  eructations,  vomitings^ 
diarrhea  and  dysentery  are  not  unfrequent  with  those  whose 
teeth  are  thus  affected. 

For  the  chemical  constituents  of  salivary  calculus,  the 
reader  is  referred  to  a  subsequent  chapter,  where,  also,  the 
morbid  effects  produced  by  its  several  varieties  are  treated 
of  more  at  large. 


CH  APT  ER    FIFTH. 

PHYSICAL  CHARACTERISTICS  OF  THE  FLUIDS  OF  THE 

MOUTH, 

In  treating  ii]3on  the  physical  characteristics  of  the  fluids 
of  the  mouth,  it  will  not  he  necessary  to  dwell  at  much 
length  on  their  effects^,  when  in  a  morbid  condition,  on  this 
cavity.  Concerning  their  agency  in  the  production  of  caries 
of  the  teeth,  we  shall  add  one  or  two  remarks. 

Saliva,  in  healthy  persons  having  good  constitutions,  has 
a  light  frothy  appearance^  and  hut  little  viscidity.  Inflam- 
mation of  the  gums  from  whatever  cause  produced,  increases 
its  viscidity,  and  causes  it  to  be  less  frothy.  In  a  healthy 
state,  it  is  inodorous,  floats  upon  and  mixes  readily  with 
water,  but  when  in  a  viscid  or  diseased  condition^  it  sinks 
and  mixes  with  it  with  difficulty. 

Irritation  in  the  mouth,  from  diseased  gums,,  aphthous 
ulcers,  inflammation  of  the  mucous  membrane,  the  intro- 
duction of  mercury  into  the  system,  or  taking  any  thing- 
pungent  into  the  mouth,  increases  the  flow  of  this  fluid,  and 
causes  it  to  be  more  viscid  than  it  is  in  its  natural  and 
healthy  state. 

In  treating  on  the  signs  of  the  saliva.  Professor  Schill 
says^  "The  sympathetic  afiection  of  the  stomach  in  preg- 
nancy is  sometimes  accompanied  by  salivation,  which,  in 
this  case  mostly  takes  place  after  conception,  and  sometimes 
continues  to  the  time  of  delivery.  It  is  also  observed  to 
occur  in  weakened  digestion,  in  gastric  catarrhs,  after  the 
use  of  emetics,  in  mania,  in  what  are  called  abdominal  ob- 
structions, in  hypochondriasis  and  hysteria  ;  salivation  oc- 
curs during  the  use  of  mercury  or  antimony. 


CHARACTERISTICS   OF  THE   FLUIDS   OF   THE   MOUTH.  241 

''In  confluent  small-pox,  salivation  is  a  favorable  sign. 
If  it  cease  before  the  ninth  day  the  prognosis  is  bad.  In 
lingering  intermittents,  salivation  is  sometimes  critical ; 
more  frequently  in  these  affections  it  precedes  the  termina- 
tion in  dropsy. 

''Diminution  of  the  salivary  secretion,  and^  in  conse- 
quence of  this,  dryness  of  the  mouth,  is  peculiar  to  the 
commencement  of  acute  disease,  as  also  to  the  hectic  fevers 
occasioned  by  affections  of  the  abdominal  organs.  If  the 
flow  of  the  saliva  stop  suddenly,  there  is  reason  to  appre- 
hend an  affection  of  the  brain. 

"Thick  viscid  saliva  occurs  under  the  same  circumstances 
as  the  diminution  of  the  salivary  secretion^  especially  in 
small  pox,  typhus,  and  in  hectic  fevers.  It  is  thin  in  ptyal- 
ism.  In  gastric  diseases,  where  the  liver  participates,  it 
becomes  yellow  or  green ;  by  the  admixture  of  blood  it  may 
assume  a  reddish  color ;  in  pregnant  or  lying-in  women,  it 
is  sometimes  milky ;  an  icy  cold  saliva  was  observed  by  the 
author  in  face-ache. 

"Frothy  saliva  from  the  mouth  is  observed  in  aj^oplexy, 
epilepsy,  hydrophobia,  and  in  the  hysterical  paroxysms."* 
Dr.  Bell,  of  Philadelphia,  in  a  note  to  the  work  from 
which  we  have  just  quoted,  says,  "acid  saliva  is  regarded 
by  M.  Donne,  as  indicative  of  gastritis  or  deranged  diges- 
tion. Mr.  Laycock/'  he  observes,  "on  the  other  hand,  in- 
fers from  numerous  experiments  on  hospital  patients,  that 
the  saliva  may  be  acid,  alkaline,  or  neutral,  when  the  gas- 
tric phenomena  are  the  same.  In  general,  Mr.  L.  remark- 
ed, that  it  was  alkaline  in  the  morning  and  acid  in  the 
evening." 

We  have  had  occasion  to  observe,  that  the  acid  quality  of 
the  saliva  was  more  apparent,  and  more  common  in  lym- 
phatic, mucous  and  bilious  dispositions,  than  in  sanguineus 
or  in  sanguino-serous  persons,  and  that  weakened  or  im- 
paired digestion  always  had  a  tendency  to  increase  it. 

*  Outlines  of  Pathological  Semeiology  ;  edition  of  the  Select  Medical  Library,  pp. 
173-4. 


242  CHARACTEIIISTICS   OF   THE   FLUIDS   OF   THE  MOUTH. 

M.  Delabarre  says,  "when  this  fluid,"  (the  saliva,)  "has 
remained  in  the  mouth  some  moments,,  it  there  obtains  new 
properties,  according  to  each  individual's  constitution  and 
the  integrity  of  the  mucous  membrane,  or  some  of  the  parts 
which  it  covers. 

"In  subjects  who  enjoy  the  best  health,  whose  stomach 
and  lungs  are  unimpaired,  the  saliva  appears  very  scarce, 
but  this  is  because  it  passes  into  the  stomach  almost  as  soon 
as  it  is  furnished  by  the  glands  that  secrete  it.  It  only 
remains  long  enough  in  the  mouth  to  mix  with  a  small 
quantity  of  mucus,  and  absorb  a  certain  portion  of  atmos- 
pheric air,  to  render  it  frothy. 

"On  the  other  hand,  the  saliva  of  an  individual  whose 
mucous  system  furnishes  a  large  quantity  of  mucus,  is 
stringy  and  heavy;  is  but  slightly  charged  with  oxygen, 
contains  a  great  proportion  of  azote  and  sulphur,  and  stains 
silver.'"^' 

Increased  redness  and  irritability  of  the  mucous  mem- 
brane of  the  mouth,  is  an  almost  invariable  accompaniment 
of  general  acidity  of  these  fluids.  Excoriation  and  aph- 
thous ulcers,  and  bleeding  of  the  gums,  also,  frequently  re- 
sult from  this  condition  of  the  salivary  and  mucous  secre- 
tions of  this  cavity. 

Anorexia,  languor,  general  depression  of  spirits,  head- 
ache, diarrhea,  and  rapid  decay  of  the  teeth,  are  very  com- 
mon among  persons  habitually  subject  to  great  viscidity  of 
the  buccal  fluids.  It  is  likewise  among  subjects  of  this  kind, 
and  particularly  when  the  viscidity  is  so  great  as  to  cause 
clamminess  of  these  secretions,  that  the  green  discoloration 
of  the  enamel  of  the  teeth  is  most  frequently  met  with. 

*Vide  Traite  de  la  Seconde  Dentition, 


CHAPTER    SIXTH. 

Pin^SICAL  CHARACTERISTICS  OF   THE  LIPS. 

The  indications  of  the  physical  characteristics  of  the  lips 
are  more  general  than  local,  and  the  observations  of  La- 
forgue  and  Delabarre  on  this  subject,  leave  little  to  be 
added.  We  cannot,  therefore,  do  much  more  than  repeat 
what  they  have  said. 

''The  lips/'  says  Delabarre,  "present  marked  diiferences 
in  different  constitutions.  They  are  thick,  red,  rosy  or 
pale,  according  to  the  qualities  of  the  arterial  blood  that 
circulates  through  their  arteries." 

Firmness  of  the  lips,  and  a  pale  rose  color  of  the  mucous 
membrane  that  covers  them,  are,  according  to  Laforgue, 
indicative  of  pure  blood,  and,  as  a  consequence,  of  a  good 
constitution.  Eedness  of  the  lips,  deeper  than  that  of  the 
pale  rose,  is  also  mentioned,  as  one  of  the  signs  of  sanguino- 
serous  blood.  Soft  pale  lips  are  indicative  of  lymphatico- 
serous  dispositions.  In  these  subjects  the  lips  are  almost 
entirely  without  color.  When  there  is  a  sufficiency  of 
blood  the  lips  are  firm,  though  variable  in  color,  according 
to  the  predominancy  of  the- red  or  serous  parts  of  this  fluid. 

Both  hardness  and  redness  of  the  lips,  and  all  the  soft 
parts  of  the  mouthy  are  enumerated  among  the  signs  of 
plethora.  Softness  of  the  lips,  without  change  of  color  in 
their  mucous  membrane,  is  spoken  of  by  the  last  author  as 
indicative  of  deficiency  of  blood;  and  softness  and  redness 
of  the  mucous  membrane  of  the  lips  are  signs  that  the 
blood  is  small  in  quantity  and  sanguino-serous. 

Serous  ancemia  and  pale  blood  are  indicated  by  want  of 
color  and  softness  of  the  lips,  and  general  paleness  of  the 
mucous  membrane  of  the  whole  mouth. 


244  CHARACTERISTICS   OF   THE  LIPS. 

^'The  fluids  contained  in  the  vessels,  says  Laforgue  in  the 
three  foregoing  forms  of  anaemia,  ''yield  to  the  slightest 
pressure,  and  leave  nothing  between  the  fingers  but  the  skin 
and  cellular  tissue." 

In  remarking  upon  the  signs  of  the  different  qualities  of 
the  blood,  the  above  mentioned  author  asserts  that  the  con- 
stitution of  children,  about  the  age  of  six  years,  cannot,  by 
a  universal  characteristic,  be  distinguished,  but  that  the 
lips,  as  well  as  other  parts  of  the  mouth,  constantly  betoken 
"the  quality  of  the  blood  and  that  of  the  flesh;"  and, 
"consequently,  they  proclaim  health  or  disease,  or  the  ap- 
proach of  asthenic  and  adynamic  disorders,  which  the  blood 
either  causes  or  aggravates." 

Again,  he  observes,  that  the  blood  of  all  children  is  "su- 
perabundantly serous,"  but  that  it  is  redder  in  those  of  the 
second  constitution  than  in  those  of  any  of  the  others;  and 
that  this  is  more  distinctly  indicated  by  the  color  of  the  lips. 
"This  quality  of  the  blood,"  says  he^  "is  necessary  to  dis- 
pose all  the  parts  to  elongate  in  their  growth.  When  the 
proportions  of  the  constituent  elements  of  the  blood  are  just, 
growth  is  accomplished  without  disease.  If  the  proportions 
are  otherwise  than  they  should  be  for  the  preservation  of 
the  health,  or  if  one  or  more  of  its  elements  be  altered, 
health  no  longer  exists,  growth  is  arrested  altogether,  or  is 
performed  irregularly.  The  nutritive  matter  is  imperfect — 
assimilation  is  prevented  or  impaired.  On  the  other  hand, 
disintegration  decomposes  the  patient ;  if  death  does  not 
sooner  result,  it  will  consume  him  by  the  lesion  of  some 
vital  organ,"* 

The  changes  produced  in  the  color  of  the  blood  by  or- 
ganic derangement  are  at  once  indicated  by  the  color  of  the 
lips. 

The  accuracy  of  Laforgue's  observations  on  the  indica- 
tions of  the  physical  characteristics  of  the  lips,  has  been 
fully  confirmed  by  subsequent  writers.     Delabarre^.  in  his 

*  Vide  Seimeiologie  Buccale  et  Buccamancie. 


CHARACTERISTICS  OF   THE  LIPS.  245 

remarks  on  tlie  semeiology  of  tlie  moutli,  has  added  noth- 
ing to  them. 

"The  secretion  of  the  lips,"  says  Professor  Schill,  "has  a 
similar  diagnostic  and  jjrognostic  import  to  that  of  the 
tongue  and  gums.  They  become  dry  in  all  fevers  and  in 
sj)asmodic  paroxysms.  A  mucous  white  coating  is  a  sign  of 
irritation  or  inflammation  of  the  intestinal  canal ;  accord- 
ingly, this  coating  is  found  in  mucous  obstructions,  in  gas- 
tric intermittent  fever,  in  mucous  fever,  and  before  the 
gouty  paroxysm.  A  dry  brown  coating  of  the  lips  is  a 
sign  of  colliquation  in  consequence  of  typhus  affections ;  it  is 
accordingly  observed  in  typhus,  in  putrid  fever,  in  acute  ex- 
anthema, and  inflammations  which  have  become  nervous."* 

The  appearances  of  the  lips,  however,  do  not  present  so 
great  a  variety  as  those  of  other  parts  of  the  mouth,  for  the 
reason  that  they  are  not  as  subject  to  local  diseases,  but 
their  general  pathological  indications  are,  perhaiDS,  quite  as 
decided. 

*  Vide  Pathological  Semeiology f  p.  152. 


CHAPTER     SEVENTH. 

PHYSICAL  CHARACTERISTICS  OF  THE  TONGUE. 

The  appearance  of  the  tongue,  both  in  health  and  disease, 
is  regarded  by  physicians  as  furnishing  more  correct  indica- 
tions of  the  state  of  the  constitution  and  general  health, 
than  any  of  the  other  parts  of  the  mouth.  It  is  asserted, 
however,  by  others,  and  by  those^.  too,  who  have  the  very  best 
opportunities  for  inspecting  the  various  parts  of  this  cavity, 
that  the  lips  and  gums  furnish  as  marked  and  reliable  indi- 
cations as  the  tongue.  That  the  state  and  quality  of  the 
blood  can  be  as  readily  ascertained  by  an  examination  of 
these,  as  by  that  of  the  tongue,  is^  we  believe,  undeniable, 
but  that  the  pathological  condition  of  the  body  can,  is  a 
question  we  leave  for  others  to  decide. 

So  far  as  the  quality  of  the  blood  and  the  temperament  of 
the  subject  are  indicated  by  the  color  of  the  tongue,  the  pre- 
ceding remarks  concerning  the  lips  will  be  found  applica- 
ble. The  one  is  as  much  influenced  by  them  as  the  other. 
It  will,  therefore,  be  unnecessary  to  recapitulate  what  we 
have  before  said  upon  the  subject. 

The  efiects  produced  on  the  mucous  membrane  of  the 
tongue,  by  disease  in  another  part,  are  said  to  be  analo- 
gous to  tliose  produced  on  the  general  integument.  So, 
also,  are  the  changes  of  its  color,  consistence,  humidity  and 
temperature  similar  to  those  of  the  skin.  We  are  likewise 
told  that  the  changes  of  its  coating  agree  with  the  analo- 
gous changes  of  the  perspiration,  and  that  these  phenomena 
are  more  decided  in  acute  than  in  chronic  affections.* 

'•"Vide  Professor  Schill's  Semeiology. 


CHARACTERISTICS  OF   THE   TONGUE.  247 

But  the  diagnostic  and  prognostic  indications  of  tlie  tongue 
vary  according  to  tlie  temperament  and  constitutional  pre- 
disposition of  the  individual.  The  physician  should  ac- 
quaint himself  with  its  appearances  in  health,  to  he  able  to 
determine  correctly  its  indications  in  disease.  He  should 
likewise  inform  himself  of  the  changes  produced  in  its  ap- 
pearance by  certain  morbid  conditions  of  the  body.  In  some 
subjects  it  is  always  slightly  furred,  especially  near  its  root, 
and  rather  dry  ;  in  others  it  is  always  clean  and  humid  ;  in 
some,  again,  it  is  always  red,  and  in  others  pale. 

Professor  Schill  divides  the  signs  of  the  tongue  into  ob- 
jective and  subjective.  To  the  objective,  "the  changes  of 
size,  form,  consistence,  color,  temperature,  secretion,"  and 
those  of  its  motion  belong;"  and  "to  the  subjective,  the 
anomalous  sensations  of  taste."  We  do  not  know,  however, 
that  any  advantage  can  be  derived  from  this  classification. 

In  enumerating  the  pathognomic  signs  of  the  tongue, 
this  author  says  that  hyj^ertrophy,  inflammation  or  conges- 
tion, may  occasion  its  enlargement ;  and  that  inflammatory 
swelling  of  it,  when  arising  from  acute  diseases,  such  as 
"angina,  pulmonary  inflammation,  measles,  plague,  or 
variola,  yields  an  unfavorable  prognosis.  Even  non-inflam- 
matory swelling  of  the  tongue,  is  a  dangerous  phenomenon 
in  acute  diseases,  especially  cerebral,  which  are  combined 
with  coma.  If  it  be  the  consequence  of  mercury,  of  tlie 
abuse  of  spirituous  drinks,  of  gastric  inflammation,  of  chlo- 
rosis, of  syphilis,  or  if  it  occur  in  hysteria  or  epilepsy,  the 
prognosis  is  not  dangerous  ;  but  the  disease  is  always  the 
more  tedious  where  the  tongue  swells  than  where  it  does  not. 
It  is  enlarged,  also,  by  degenerescence  and  cancer." 

"Diminution  of  the  size  of  the  tongue  takes  place  where 
there  is  considerable  emaciation.  In  this  case  it  continues 
soft  and  movable.  If  in  acute  states,  the  tongue  becomes 
small,  and  is,  at  the  same  time,  hard,  retracted  and  pointed, 
the  irritation  is  very  great,  and  the  prognosis  bad.  This 
sign  occurs  more  especially  in  typhus,  in  the  oriental  cliole- 
ra,  in  inflammation  of  the  lungs,  and  in  acute  cerebral  afiec- 


248  CHARACTERISTICS   OF   THE  TONGUE. 

tions.     In  liysteria  and  epilepsy  this  plienomenon  lias  no 
unfavorable  import." 

Internal  maladies,  lie  says,  seldom  cause  the  form  of  the 
tongue  to  change,  but  that  the  slightest  change  arising 
from  chronic  irritations  of  the  stomach,  chronic  dyspepsia^ 
and  acute  exanthems,  is  enlargement  of  its  papillae.  In 
cases  of  protracted  dyspepsia,  the  edges  of  the  tongue  some- 
times cracky  and  in  paralysis  and  epilepsy,  it  becomes 
elongated. 

In  acute  diseases,  a  soft  tongue  is  a  favorable  indication, 
and  flaccidity  of  it,  that  of  debility. 

Humidity  of  the  tongue,  he  tells  us,  is  a  favorable  sign, 
and  that  dryness  of  it  occurs  in  acute  or  violent  inflamma- 
tions and  irritations,  and  more  particularly  when  seated  in 
the  intestinal  canal,  and  respiratory  organs.  "This  also 
happens  in  diarrhea,  typhus,  pneumonia,  gangrene  of  the 
lung,  pleuritus,  peritonitis,  enteritis,  catarrhous  gastricus, 
gastritis,  inflammation  of  joints,  etc.  Among  the  higher 
degrees  of  dryness,  he  enumerates  the  rough,  the  fissured 
and  burnt  tongue,  as  furnishing  still  more  unfavorable  indi- 
cations, informing  us  at  the  same  time,  that  if  these  be  not 
accompanied  by  thirst,  they  prognosticate  a  fatal  termina- 
tion. The  abatement  and  crisis  of  the  disease  is  indicated 
by  the  tongue  becoming  moist." 

Dr.  Bell,  of  Philadelphia,  in  a  note  to  Professor  Schill's 
observations  on  the  tongue,  says,  "a  rough  and  dry,  and 
even  furred  tongue,  is  seen  in  some  dyspeptic  persons,  who 
sleep  with  the  mouth  open ;  and  although  it  indicates  an 
irritation  of  the  digestive  organs,  it  is  not  of  a  bad  augury." 
Bilious  persons,  not  unfrequently,  though  not  troubled  with 
any  manifest  symptoms  of  gastric  or  intestinal  derangement 
or  any  other  apparent  functional  disturbance,  have  a  furred 
tongue  in  the  morning. 

Paleness  of  the  tongue,  says  Professor  Schill,  is  a  sign  of  a 
serous  condition  of  the  blood,  of  chlorosis,  of  great  loss  of 
blood,  of  chronic  disorders,  of  sinking  of  the  strength  in 
acute  maladies,  assuming  a  "nervous  form,  as  typhus  and 


CHARACTERISTICS   OF   THE  TONGUE.  249 

scarlatina  maligna.  It  is  also  found/'  says  lie,  "in  enteritis 
and  dysentery,  when  but  little  fever  is  present. ' '  He  infers 
from  tliis,  that  paleness  of  the  tongue  is  caused  by  the 
"drawing  of  the  fluids  downwards,"  but  it  is  often  observed 
in  persons  who  enjoy  tolerably  good  health.  Lymphatic 
dispositions,  as  has  been  before  remarked,  are  peculiarly 
subject  to  it. 

Again,  he  observes,  that  a  very  red  tongue  is  indicative 
of  "violent  inflammation,  mostly  of  the  intestinal  canal, 
but  also  of  the  lungs,  of  the  pharynx  and  of  acute  exan- 
thems."  He  regards  the  prognosis  as  bad,  when  a  furred 
tongue  "in  acute  diseases  of  the  intestinal  canal  becomes 
clean  and  very  red,"  if  the  change  is  not  accompanied  with 
the  return  of  the  patient's  strength.  "But,"  he  continues, 
"if  the  debility  is  not  considerable^,  and  the  tongue  becomes 
clean  and  very  red,  whilst  other  febrile  symptoms  continue, 
a  new  inflammation  may  be  expected."  But  even  in  afiec- 
tions  like  these,  the  redness  of  the  tongue  is  always  more 
considerable  in  sanguineus,  than  in  lymphatic  or  lym- 
phatico-serous  subjects,  so  that  in  forming  a  prognosis  from 
this  sign,  the  temperament  of  the  individual  should  never 
be  overlooked. 

Proceeding  with  the  description  of  the  signs  of  this  organ, 
he  says,  "the  tongue  becomes  a  blackish-red  and  bluish-red 
in  all  serious  disturbances  of  the  circulation  and  respiration, 
as  also  in  severe  diseases  of  the  lungs  and  heart,  as  catarrhs, 
suffocations,  asthma,  extensive  inflammations  of  the  lungs^ 
carditis,  Asiatic  cholera,  plague,  confluent  small-pox,  and 
putrid  fevers.  It  becomes  black  and  livid  in  cases  of  vitia- 
tion of  the  blood,  more  especially  in  scurvy,  at  the  setting 
in  of  gangrene,  and  in  phthisis,  when  death  is  near  at 
hand." 

Among  the  diseases  mentioned  as  giving  rise  to  an  in- 
crease of  the  temperature  of  the  tongue,  are  glossitis,  violent 
internal  inflammation  and  typhus  fever ;  and  coldness  of  this 
organ  is  observed  to  take  place  in  Asiatic  cholera,  and  at  the 
approach  of  death . 
17 


250  CHARACTERISTICS   OF   THE   TONGUE. 

The  signs  from  the  secretion  of  the  tongue  are  thus  enu- 
merated. A  clean  and  moist  tongue  are  favorable  indica- 
tions, but  a  clean,  dry  and  red  tongue,  as  are  seen  in  slow 
nervous  fevers,  acute  exanthems  and  plague,  are  bad  augu- 
ries. A  furred  or  coated  tongue  is  said  to  occur  chiefly  in 
intestinal  disorders,  diseases  of  the  lungs,  skin,  and  in 
rheumatic  affections.  The  coating  is  said  to  vary  in  ''color, 
thickness,  adherence,  and  extent,"  and  different  kinds  of 
secretion  from  the  mucous  membrane  of  this  organ  are 
mentioned  as  occurring  in  different  diseases,  and  it  should 
have  been  added  in  the  same  disease  in  different  tempera- 
ments. 

After  describing  the  various  kinds  of  coating  on  the  tongue, 
together  with  their  respective  indications^  which  it  is  not 
necessary  here  to  enumerate,  the  occurrence  of  false  mem- 
branes and  pustules,  resulting  from  peculiar  forms  of  mucous 
secretion,  are  next  mentioned.  The  former  show  them- 
selves either  as  small  white  points,  or  large  portions,  and 
sometimes  they  are  said  to  envelop  the  whole  tongue.  The 
color  is  "sometimes  white,  sometimes  yellow  and  sometimes 
red,"  and  the  greater  the  surface  covered  by  them,  the  more 
unfavorable  is  the  prognosis  regarded.  "Pustules  on  the 
tongue,"  says  our  author,  "are  sometimes  idiopathic,  but  in 
most  cases  symptomatic.  They  are  either  distinct  or  con- 
fluent; the  confluent  are  tlie  worst.  Those  which  are 
hardish  and  dry_,  and  also  those  which  are  blue_,  and  those 
of  a  blackish  appearance,  which  sometimes  occur  in  acute 
diseases,  are  of  an  unfavorable  import."  On  the  other 
hand,  those  which  have  a  whitish,  soft,  moist,  and  semi- 
transparent  appearance,  are  less  unfavorable,  and  when  the 
eruption  or  aphthae  is  repeated,  it  portends  a  longer  contin- 
uance of  the  malady.  To  the  following  diseases,  they  are 
mentioned  as  being  frequent  accompaniments;  namely, 
gastritis,  catarrhs,  anteritis,  metritis,  dysentery,  cholera 
infantum^  peritonitis,  intermittent  and  typhus  fevers,  pleu- 
ritis,  pneumonia,  and  the  third  stage  of  pulmonary  con- 
sumption.    Their  prognosis  is  said  to  be  favorable,  when 


CHARACTERISTICS    OF   THE   TONGirE.  251 

"they  appear  with  critical  discharges  after  the  seventh 
day,"  and  unfavorable,  when  they  occur  as  a  consequence  of 
a  general  sinking  of  the  physical  powers  of  the  body.* 

But  it  is  unnecessarv  to  enumerate  all  of  the  pathognomic 
indications  of  the  various  morbid  jjhenomena  described  by 
semeiologists ;  we  have  noticed  more  of  them  than  was  our 
intention  to  have  done.  We  shall,  therefore,  conclude  the 
present  inquiry,  by  simply  observing,  that  the  indications 
furnished  by  the  physical  characteristics,  of  not  only  the 
tongue,  but  those,  also,  of  the  teeth,  tlie  gums,  salivary  cal- 
culus, the  lips  and  fluids  of  the  mouth,  are,  as  we  have 
endeavored  to  show,  essential  to  the  successful  exercise  of 
the  duties  both  of  the  dental  and  medical  practitioner. 

*  Vide  Professor  Schill's  Semeiology . 


P^RT    THIRD. 


DISEASES  OF  THE  TEETH  AND  THEIR  TREATMENT. 
DISLOCATION  OF  THE  LOWER  JAW, 


I>A.RT     THII^D. 


DISEASES  OF  THE   TEETH. 

The  doctrine  that  tlie  diseases  of  the  teeth  are  the  same 
as  those  which  attack  other  osseous  structures  of  the  body, 
as  promulgated  by  Fox,  and,  subsequently,  advocated  by 
Bell,  and  other  European  writers,  is  now  almost  univer- 
sally conceded  to  be  incorrect.  With  the  exception  of  ex- 
ostosis and  necrosis,  the  pathological  conditions  of  these  or- 
gans do  not  bear  the  slightest  analogy  to  those  of  other 
bones.  They  are  not  produced  by  the  same  causes,  nor  can 
they  be  cured  by  the  same  remedies.  In  the  treatment  of 
those  of  the  former,  art  must  do  all ;  in  those  of  the  latter, 
the  recuperative  powers  of  the  economy  are  the  resources 
principally  to  be  relied  on. 

The  teeth  are  more  liable  to  be  attacked  by  caries  than 
any  other  disease,  and  this,  therefore,  will  first  claim  our 
attention. 


CHAPTER     FIRST. 

CARIES  OF  THE  TEETH. 

Caries  of  a  tootli  is  the  chemical  decomposition  of  the 
earthy  salts  of  the  affected  part,  sometimes,  but  not  always, 
accompanied  by  the  disorganization  of  the  animal  frame 
work  of  this  portion  of  the  organ.  There  is  no  affec- 
tion to  which  these  organs  are  liable,  more  frequent  in  its 
occurrence,  or  fatal  in  its  tendency,  than  this.  It  is  often 
so  insidious  in  its  attacks,  and  rapid  in  its  progress,  that 
every  tooth  in  the  mouth  is  involved  in  irreparable  ruin, 
before  its  existence  is  scarcely  suspected. 

Its  presence  is  usually  first  indicated  by  an  opaque  or 
dark  spot  on  the  enamel ;  and,  if  this  be  removed,  the  sub- 
jacent dentine  will  exhibit  a  black,  dark-brown  or  whitish 
appearance.  It  usually  commences  on  the  outer  surface  of 
the  dentine  of  the  crown,  beneath  the  enamel,  at  some 
point  where  it  is  imperfect  or  has  been  fractured  or  other- 
wise injured  ;  from  thence  it  proceeds  towards  the  centre  of 
the  tooth,  increasing  in  circumference,  until  it  reaches  the 
pulp  cavity. 

If  the  diseased  part  is  of  a  soft  and  humid  character,  the 
enamel,  after  a  time,  usually  breaks  in,  disclosing  the  rav- 
ages the  disease  has  made  on  the  subjacent  dentine.  But 
this  does  not  always  happen;  the  form  of  the  tooth  some- 
times remains  nearly  perfect,,  until  its  whole  interior  struc- 
ture is  destroyed. 

There  is  no  portion  of  the  crown  or  neck  of  a  tooth  ex- 
empt from  the  disease  ;  yet,  some  parts  are  more  liable  to 
be  first  attacked  than  others;  as,  for  example,  the  depres- 
sions in  the  grinding  surfaces  of  the  molars  and  bicuspids, 


CARIES   OF   THE   TEETH.  25 Y 

the  approximal  surfaces  of  all  the  teeth — the  posterior  or 
palatine  surfaces  of  the  lateral  incisors  ;  and,  in  short, 
wherever  an  imperfection  of  the  enamel  exists. 

The  enamel  is  much  harder  than  the  dentine,  and  is  by- 
far  less  easily  acted  on  by  the  causes  that  produce  the  dis- 
ease. It  is  sometimes,  however,  first  attacked,  and  when 
this  happens,  the  disease  develops  itself  more  frequently  on 
the  labial,  or  buccal  surface  near  the  gum,  than  in  any 
other  locality — often  commencing  at  a  single  point,  and  at 
other  times  at  a  number  of  points.  When  the  enamel  is 
first  attacked,  it  is  usually  called  erosion;  but  as  this  tissue 
does  not  contain  so  much  animal  matter  as  the  subjacent 
dentine,  the  diseased  part  is  often  washed  away  by  the  sali- 
va of  the  mouth,  while  in  the  dentinal  part  of  the  tooth,  it, 
in  most  instances,  remains,  and  may  be  removed  in  distinct 
laminae,  after  the  earthy  salts  have  been  decomposed. 

In  very  hard  teeth,  the  decayed  part  is  of  a  firmer  con- 
sistence, and  of  a  darker  color,  than  in  soft  teeth.  Some- 
times it  is  black ;  at  other  times  of  a  dark  or  light  brown ; 
and  at  other  times  again,  it  is  nearly  white.  As  a  general 
rule,  the  softer  the  tooth,  the  lighter,  softer  and  more  hu- 
mid the  caries.  The  color  of  the  decayed  part,  however, 
may  be,  and  doubtless  is,  in  some  cases,  influenced  by  other 
circumstances — perhaps  by  some  peculiar  modification  of  the 
agents  concerned  in  the  production  of  the  disease. 

The  disease  then,  not  being  the  result  of  any  vital  action, 
the  applicability  of  the  term  caries  may  be  questioned ;  but, 
as  it  has  been  very  generally  sanctioned,  and  as  we  know  of 
no  better  name,  we  shall  continue  its  use.  Mr.  Bell  has 
substituted  the  term  gangrene,  under  the  belief  that  it  con- 
veys a  more  correct  idea  of  the  true  nature  of  the  affection. 
The  applicability  of  a  term,  almost  synonymous  with  this, 
is  also  suggested  by  Mr.  Hunter;  who,  in  speaking  of  the 
afiiection,  says,  it  ''appears  to  deserve  the  name  of  mortifi- 
cation." Mr.  Fox,  too,  treats  of  the  decay  of  the  teeth,  as 
a  disorder  which  terminates  in  mortification,  but  he  desig- 
nates it  by  the  name  of  caries,  and  we  prefer  this  term,  in- 


258  CARIES   OF   THE   TEETH. 

asmiich  as  that  of  gangrene  or  mortification  may  be  applied 
to  another  condition  of  the  teeth  ;  namely,  necrosis,  with  as 
much  propriety  as  to  the  one  now  under  consideration. 
Moreover,  the  term  gangrene,  or  mortification,  is  usually 
used  to  signify  the  death  of  a  soft  part,  and  not  a  diseased 
condition  of  a  bony  tissue. 

Commencing  externally  beneath  the  enamel,  the  disease 
proceeds,  as  we  have  before  stated,  towards  the  centre  of  the 
tooth,  destroying  layer  after  layer,  until  it  reaches  the  lin- 
ing membrane,  leaving  each  outer  stratum  softer,  and  of  a 
darker  color  than  the  subjacent  one. 

The  appellations,  deep  seated,  superficicd,  external  and 
internal,  simple  and  complicated,  have  been  applied  to  the 
disease.  These  distinctions  are  unnecessary,  since  they 
only  designate  the  different  stages  of  the  same  affection. 
By  complicated  decay,  is  meant  caries  which  has  penetrated 
to  the  pulp  cavity  of  the  tooth,  accompanied  by  inflamma- 
tion and  suppuration  of  the  lining  membrane,  and  the  death 
of  the  organ.  The  lining  membrane,  however,  is  not  al- 
ways inflamed  by  exposure,  nor  suppurated  by  inflamma- 
tion. 

Equally  unnecessary  is  the  classification  adopted  by  M. 
Duval,  to  designate  the  differences  of  color  and  consistence 
exhibited  by  the  decayed  part.  He  enumerates  seven  varie- 
ties or  species,  which  are  as  follows :  calcareous,  peeling, 
perforating ,  black,  deruptive,  stationary  and  luasting. 

T1\\Q  first,  he  employs  to  denote  that  affection  of  the  teeth 
characterized  by  the  appearance  of  a  white  opaque  spot  on 
the  enamel,  whereby  it  is  rendered  brittle^  and  often  caused 
to  break.  The  second,  if  not  identical  with,  is  at  least 
analogous  to  the  first — the  difference  consisting  only  in  the 
color  of  the  enamel.  The  third,  from  a  defect  in  almost 
every  part  of  the  enamel  covering  the  crowns  of  the  teeth, 
attacks  the  molars  and  sometimes  the  bicuspids,  at  a  num- 
ber of  points  simultaneously,  causing  speedy  destruction. 
The  fourth,  he  describes  as  not  occurring  until  from  the  fif- 
teenth to  the  thirtieth  year,  and  as  being  principally  con- 


DIFFERENCES   IN   LIABILITY   OF   TEETH   TO   DECAY.  259 

fined  to  persons  of  consumptive  habits,  and  those  disposed  to 
rachitis.  The  color  of  the  decayed  part  of  a  tooth  in  indi- 
viduals having  such  morbid  proclivity,  is  sometimes  black, 
but  more  frequently  white.  Black  caries^  as  jt  is  called,  is 
oftener  met  with  in  the  teeth  of  persons  of  good  constitu- 
tions, and  in  hard  rather  than  soft  teeth. 

The  jiftli  species,  or  deruptive,  he  represents  as  that 
which  attacks  the  front  teeth  of  individuals  of  consumptive 
habits  near  the  necks  of  the  organs,  extending  downwards 
towards  their  roots,  and  forming  a  brownish  semicircular 
groove.  The  sixth,  is  that  description^  which,  after  having 
penetrated  a  certain  distance  into  the  substance  of  the  tooth, 
becomes  stationary.  The  seventh  and  last  species^  is  charac- 
terized by  the  gradual  wasting  of  the  grinding  surfaces  of 
the  molars^  dipping  down  in  some  places  to  a  considerable 
depth,  and  leaving  a  smooth  polished  surface  of  a  brown  or 
yellowish  color. 

Finally,  the  roots  of  the  teeth  frequently  remain  firm  in 
their  sockets  for  years  after  the  crowns  and  necks  have  been 
destroyed,  showing  that  they  are  less  liable  to  decay  than 
the  crowns  ;  but  nature,  after  the  destruction  of  the  last,  as 
if  conscious  that  the  former  are  of  no  further  use,  exerts  her- 
self to  expel  them  from  the  system,  which  is  efiected  by  the 
gradual  wasting  and  filling  up  of  their  sockets.  It  often 
happens,  that  after  this  operation  of  the  economy  has  been 
accomplished,  they  are  retained  in  the  mouth  for  months, 
and  oftentimes  for  years,  by  their  periosteal  connections 
with  the  gums.  But  this  effort  of  nature,  is  confined  more 
to  the  back  than  to  the  front  teeth,  for  it  often  happens  that 
the  last  remain  for  a  great  number  of  years,  and  sometimes 
seemingly  without  much  injury  to  the  parts  within  which 
they  are  contained,  after  the  destruction  of  the  crowns. 

DIPFERENCKS  IN  THE  LIABILITY  OP  DIFFERENT  TEETH  TO  DECAY. 

Having  explained  at  some  length,  in  a  preceding  part  of 
this  work,   the  manner  in  which  the  physical  condition  of 


260  DIFFERENCES  IN   LIABILITY   OF  TEETH  TO   DECAY. 

the  teeth  is  influenced,  it  will  not  be  necessary  now  to  dwell 
upon  this  portion  of  our  subject.  It  will  only  be  requisite  to 
state,  therefore,  that  teeth  which  are  well  formed,  well  ar- 
ranged and  of  a  firm  texture,  seldom  decay,  and  when  they 
are  attacked_,  the  progress  of  the  disease  is  not  rapid; 
whereas,  those  that  are  imperfect  in  their  formation,  and  of 
a  soft  texture,  are  more  susceptible  to  the  action  of  the 
causes  which  produce  it,  and  when  assailed_,  if  the  progress 
of  the  affection  is  not  arrested  by  art,  they  usually  fall 
speedy  victims  to  its  ravages.  So  just  in  proportion  as  the 
dentinal  structure  of  the  teeth  is  hard  or  soft,  the  shape  of 
the  organs  perfect  or  imperfect,  their  arrangement  reg- 
ular or  irregular,  is  their  liability  to  caries  diminished  or 
increased. 

The  density,  shape  and  arrangement  of  the  teeth,  are  in- 
fluenced by  the  state  of  the  general  health,  and  that  of  the 
mouth,  at  the  time  of  their  dentinification.  If,  at  this  pe- 
riod, all  the  functions  of  the  body  are  healthily  performed, 
these  organs  will  be  compact  in  their  structure,  perfect  in 
their  shape,  and  usually  regular  in  their  arrangement. 

That  the  teeth  should  be  thus  influenced,  will  not  appear 
strange,  when  we  consider,  that  'Hhere  exists,"  as  Riche- 
rand  remarks,  ''amongst  all  the  parts  of  the  living  body, 
intimate  relations,  all  of  which  correspond  to  each  other, 
and  carry  on  a  reciprocal  intercourse  of  sensations  and  affec- 
tions." Hence,  if  there  is  a  morbid  action  in  one  part, 
other  parts  sympathize  with  it,  and,  as  if  sensible  of 
the  mutual  dependence  existing  between  them,  rally  all 
their  energies  to  rescue  their  neighbor  from  the  power  of 
disease. 

Increased  action  in  one  portion  of  the  system,  is  generally 
followed  by  diminished  action  in  some  other  part ;  thus  for 
example,  gastritis  is  usually  produced  by  constipation  of  the 
bowels:  puerperal  fever,  by  diminished  action  in  the  heart, 
and  an  increased  action  in  the  uterus,  etc.  Hence,  we  may 
conclude,  that  if  the  body,  at  an  early  age,  be  morbidly  ex- 
cited, its  functions  will  be  languidly  performed — the  process 


DIFFERENCES  IN   LIABILITY   OF   TEETH  TO  DECAY.  261 

of  assimilation  cliecked — the  regular  and  healthy  supply  of 
earthy  matter  interrupted — and  that,  consequently,  the  teeth 
which  are  then  formed,  will  he  defective.  Other  parts  of 
the  hody,  in  which  constant  changes  are  going  on,  if  thus 
affected  at  these  early  periods,  may  afterwards  recover  their 
healthful  vigor;  hut  if  the  teeth  are  hadly  formed,  they 
must  ever,  hecause  of  their  low  degree  of  organization,  con- 
tinue so,  andj  consequently,  he  more  liable  to  decay  than 
when  dentinified  under  other  and  more  favorable  circum- 
stances. 

"That  the  teeth  acquire  this  disposition,"  says  Mr.  Fox, 
''to  decay,  from  some  want  of  healthy  action  during  their 
formation,  seems  to  he  proved  by  common  observation,  that 
they  become  decayed  in  pairs;  that  is,  those  which  are 
formed  at  the  same  time,  being  in  a  similar  state  of  imper- 
fection, have  not  the  power  to  resist  the  causes  of  the  disease, 
and,  therefore^  nearly  about  the  same  period  of  time  exhibit 
signs  of  decay ;  while  those  which  have  been  formed  at  an- 
other time,  when  a  more  healthy  action  has  existed,  have 
remained  perfectly  sound  to  the  end  of  life." 

Most  writers  are  of  the  opinion,  that  the  power  of  the 
teeth  to  resist  the  various  causes  of  decay  is  sometimes 
weakened  by  a  change  brought  about  in  their  physical  con- 
dition through  the  agency  of  certain  remote  causes,  such  as 
the  profuse  administration  of  mercury,  the  existence  of 
fevers,  and  all  severe  constitutional  disorders. 

Mr.  Fox  says,  "That  he  has  had  occasion  to  observe,  that 
great  changes  take  place  iu  the  economy  of  the  teeth  in 
consequence  of  continued  fever  ;  and  that  the  decay  of  the 
teeth  is  often  the  consequence  of  certain  states  of  the  con- 
stitution." 

Mr.  Bell  remarks  :  "That  amongst  the  remote  causes,  (of 
decay,)  are  those  which  produce  a  deleterious  change  in  the 
constitution  of  the  teeth,  subsequent  to  their  formation  ;  one 
of  the  most  extensive,  in  its  effects,  is  the  use  of  mercury. 
To  the  profuse  administration  of  this  remedy  in  tropical 
diseases,  we  may,  we  think,  in  a  great  measure,  attribute 


262  DIFFERENCES  IN"   LIABILITY   OF   TEETH    TO    DECAY. 

the  injury  vvhicli  a  residence  in  hot  climates  so  frequently 
inflicts  on  the  teeth." 

Severe  constitutional  disorders,  and  the  administration  of 
certain  kinds  of  medicine,  do  not,  as  Mr.  Fox  and  Mr.  Bell 
suppose,  act  directly  upon  the  teeth,  by  altering  their  phys- 
ical condition  and  thus  rendering  them  more  susceptible  to 
the  action  of  corrosive  agents;  but  they  are  indirectly 
afiected  in  proportion  as  the  secretions  of  the  mouth  are 
vitiated  and  their  corrosive  projierties  increased. 

The  following  considerations  establish,  to  our  mind,  the 
truth  of  wliat  we  have  just  stated.  Artificial  teeth  of  bone 
or  ivory,  which  can  undergo  no  such  changes  as  those  men- 
tioned by  Mr.  Bell,  decay  more  rapidly  after  the  profuse 
administration  of  any  medicine,  or  during  the  existence  of 
any  disease  that  tends  to  vitiate  the  secretions  of  the  mouth, 
than  at  other  times.  Furthermore,  teeth  of  so  dense  a  tex- 
ure,  as  to  be  capable  of  resisting  the  action  of  the  acidu- 
lated buccal  fluids — though  just  as  liable  as  those  of  a 
spongy  texture,  to  any  disease  communicated  from  the  gen- 
eral system,  by  changing  their  internal  economy,  are  not 
affected  by  constitutional  disease. 

The  following  is  the  result  of  our  own  observations  :  The 
gums  and  alveolar  processes  are  sometimes  destroyed  by  the 
use  of  mercury,  so  that  all  the  teeth  loosen  and  drop  out, 
without  being  affected  by  caries.  The  teeth  of  persons,  in 
whom  a  mercurial  diathesis  has  been  for  a  long  time  kept 
up,  or  who  liave  been  for  years  sufiering  from  dyspepsia, 
phthisis,  fevers,  or  other  severe  constitutional  disorders, 
often  continue  perfectly  sound,  wliile  other  teeth,  under 
similar  circumstances;,  frequently  decay.  Now,  all  this 
goes  to  prove,  not  that  changes  are  effected  in  the  structural 
condition  of  the  teeth^  whereby  their  predisjiosition  to 
decay  is  increased,  but  that  there  are  differences  in  the 
capabilities  of  different  teeth  to  resist  the  action  of  the 
acrid  secretions  of  the  mouth,  caused  by  the  affections  just 
enumerated. 

The  predisposition  of  teeth  to  decay,  may.  however,  be 


DIFFERENCES   IN    LIABILITY   OF   TEETH   TO   DECAY.  263 

increased   by    improper   dental    operations,    as   injudicious 
filing,  careless  plugging,  etc. 

The  author  is  aware  that  he  differs  from  some  on  this 
point,  as  well  as  from  received  popular  opinion.  The  views 
which  he  has  here  presented,  are  not  the  result  of  mere 
closet  reflections  partially  matured,  but  of  long  and  atten- 
tive observation.  He  has  noted  the  effects  of  mercury,  and 
of  other  medicines,  as  well  as  of  constitutional  diseases  of 
the  severest  and  most  protracted  kinds,  and  he  has  always 
observed,  that  it  was  only  as  they  impaired  the  healthy 
qualities  of  the  fluids  of  the  mouth,  that  they  affected  the 
teeth.  In  fact,  the  density  of  these  organs,  their  exposed 
situation,  their  functions,  all  would  seem  to  indicate,  that 
such  changes  as  take  place  in  other  parts  of  the  body,  are 
not  only  unnecessary,  but  many  of  them  even  impossible. 

Dr.  Good  says,  '"'That  caries  of  the  teeth  does  not  appear 
to  be  a  disease  of  any  particular  age  or  temperament,  or 
state  of  health."  It  is  true  it  is  not  a  disease  of  any  par- 
ticular state  of  health,  farther  than  that  certain  constitu- 
tional affections  exert  a  deleterious  influence  upon  the  secre- 
tions of  the  mouth,  and  thus  become  indirect  causes  of 
decay  of  these  organs.  That  it  is  not  a  disease  of  any  par- 
ticular age,  seems  to  contradict  common  experience,  for  it 
comparatively  seldom  happens  that  caries  appears  after  the 
age  of  forty.  The  reason  of  which  is  obvious.  Teeth  of 
a  loose  texture,  or  otherwise  imperfect,  cannot  resist  the  ac- 
tion of  the  causes  of  decay,  to  which  all  teeth  are  more  or 
less  exposed  to  this  period  of  life,  while  those  which  from 
their  greater  density  remain  unaffected  thus  long,  are  gen- 
erally enabled,  by  the  increased  solidity  they  gradually  ac- 
quire, to  resist  them  through  life.  Teeth,  however,  do 
sometimes,  tliough  rarely,  decay  at  fifty,  or  even  at  a  later 
period.  But  caries  of  the  teeth,  generally,  may  be  said  to 
be  confined  to  }outh  and  middle  age. 

The  formation,  arrangement  and  physical  condition  of 
the  teeth,  are  sometimes  influenced  by  hereditary  diatheses 
of  the  general  system^,  or  of  the  parts  concerned  in  their 


264  DIFFERENCES   IN   LIABILITY   OF   TEETH   TO   DECAY. 

production^  and  that  a  morbid  condition  of  the  system, 
either  on  the  part  of  the  father  or  mother,  often  predisposes 
their  progeny  to  like  affections,  is  an  axiom  fully  recog- 
nized in  pathology,  and  a  fact  of  which  we  have  many  fear- 
ful proofs. 

Mr.  Bell,  in  treating  of  what  he  calls  the  hereditary  pre- 
disposition of  the  teeth  to  decay,  remarks:  "That  it  often 
happens  that  this  tendency  exists  in  either  the  whole 
or  a  great  part  of  a  family  of  children,  where  one  of  the 
parents  had  been  similarly  affected  ;  and  this  is  true  to  so 
great  an  extent,  that  we  have  commonly  seen  the  same 
tooth,  and  even  the  same  j)art  of  a  tooth,  affected  in  several 
individuals  of  the  family,  and  at  about  the  same  age.  In 
other  instances,  where  there  are  many  children,  amongst 
whom  there  exists  a  distinct  division  into  two  portions, 
some  resembling  the  father,  and  some  the  mother^  in  fea- 
tures and  constitution,  we  observe  corresponding  differ- 
ences in  the  teeth,  both  as  it  regards  their  form  and  texture, 
and  their  tendency  to  decay." 

That  there  is  an  hereditary  tendency  in  the  teeth  to  de- 
cay, cannot,  we  think,  be  denied.  But  we  believe  it  to  be 
the  result  of  the  transmission  of  a  similarity  of  action  in 
the  parts  concerned  in  tlie  production  of  these  organs,  so 
that  the  teeth  of  the  child  are,  in  form  and  structure,  like 
those  of  the  parent  whom  it  most  resembles,  and  from 
whom  it  has  inlicrited  the  diathesis.  The  teeth  of  the  child 
being  shaped  like  those  of  the  parent,  possess  a  like  degree 
of  density,  and,  in  most  instances,  similarly  arranged,  are 
equally  liable  to  disease,  and  when  exposed  to  the  action  of 
the  same  causes,  are  affected  in  like  manner^  and,  usually, 
at  about  the  same  period  of  life.  Such  being  the  fact,  is  it 
unreasonable  to  conclude,  that  judicious  early  attention 
may  so  influence  the  formation  and  arrangement  of  the 
teeth,  that  their  liability  to  disease  may  be  diminished? 
It  is,  then,  to  the  differences  in  the  })hysical  condition  and 
manner  of  arrangement  of  these  organs,  in  different  indi- 
viduals and  in  the  same  mouth,  that  the  differences  in  their 
liability  to  decay  is  attributable. 


CAUSES  OF  CARIES.  265 


CAUSES   OF   CARIES. 

Caries  of  the  teeth  has  heen  attributed  to  a  great  variety 
of  causes,  and  to  notice,  in  detail,  the  various  opinions  ad- 
vanced by  American,  English,  French  and  German  writers 
upon  this  subject,  would  be  both  inconsistent  with  the  plan 
of  an  elementary  treatise  like  this,  and  unprofitable  to  the 
reader;  we  shall,  therefore,  content  ourself  with  a  very 
brief  exposition  of  the  views  of  a  few  of  the  most  prominent 
writers,  and  if,  in  doing  this,  we  shall  have  occasion  to  dif- 
fer from  any,  we  trust  we  shall  be  able  to  give  satisfactory 
reasons  for  so  doing. 

Fauchard,  Auzebe^  Bourdet,  Lecluse,  Jourdain,  and 
most  of  the  French  writers  of  the  eighteenth  century  on 
the  diseases  of  the  teeth,  as  well  as  nearly  all  of  the  more 
modern  French  authors,  though  their  views  with  regard  to 
the  causes  of  dental  caries  are  exceedingly  vague  and  con- 
fused, express  the  belief  that  the  disease  is,  for  the  most 
part,  the  result  of  the  action  of  chemical  agents  ;  such,  for 
example,  as  vitiated  saliva,  the  putrescent  remains  of  par- 
ticles of  food  lodged  between  the  teeth,  or  in  their  intersti- 
ces, acids,  and  a  corrupted  state  of  the  fluids  conveyed  to 
these  organs  for  their  nourishment.  They  also  mention 
certain  states  of  the  general  health,  mechanical  injuries, 
sudden  transitions  of  temperature,  etc.,  as  being  conducive 
to  the  disease.  A  similar  explanation,  too,  of  the  cause  is 
given  by  Salmon,  the  author  of  a  Compendium  of  Surgery, 
published  in  London,  in  1644. 

The  foregoing  is  a  general  summary  of  the  views  enter- 
tained by  most  of  the  older  writers  with  regard  to  the  cause 
of  the  disease  under  consideration,  and,  if  they  are  not 
strictly  correct^  we  think  we  shall  presently  be  able  to  show 
that  they  are  not  altogether  erroneous. 

In  the  English  school  of  dental  surgery,  since  the  time  of 
the  publication  of  Mr.  Fox's  celebrated  treatise  on  the  Na- 
tural History  and  Diseases  of  the  Teeth,  and  until  quite  re- 
18 


266  CAUSES    OF    CARIES. 

cently,  inflammation  of  the  dentine  has  been  regarded  as 
the  proximate  or  immediate  cause  of  the  disease. 

Having  discovered  an  identity  of  structure  between  the 
teeth  and  the  bones  of  the  body,  this  author  immediately 
concluded  that  the  diseases  of  the  one  -were  identical  with 
those  of  the  other.  This  inference,  it  must  be  confessed,  to 
one  who  has  not  made  the  diseases  of  the  former  a  subject  of 
close  and  critical  investigation,  would  seem  to  be  irresisti- 
ble. But  it  is  evidently  incorrect,  so  far,  at  least,  as  most 
of  the  diseases  of  the  teeth  are  concerned.  By  instituting 
a  comparison  between  caries  of  the  teeth  and  that  of  bone, 
it  will  at  once  be  perceived  that  there  is  not  the  slightest 
analogy  between  the  disease,  as  it  occurs  in  the  one,  and 
shows  itself  in  the  other.  In  the  former,  it  consists  simply 
in  a  decomposition  of  the  earthy  salts  of  the  organs, 
whereas,  in  the  latter,  it  is  analogous  to  ulceration  in  soft 
parts,  and  constantly  discharges  fetid  sanies,  and  throws 
out  granulations  of  fungous  flesh.  These  are  phenomena 
which  dental  caries  never  present,  and  they  establish  a  wide 
difference  of  character  between  it  and  the  disease  as  occur- 
ring in  the  true  osseous  structures  of  the  body. 

But  the  promulgation  of  the  doctrine  of  the  vascularity 
of  the  teeth,  not  only  led  to  the  belief  that  caries  of  these 
organs  was  identical  with  caries  of  bones,  but  it  soon  gave 
rise  to  the  supposition,  that,  inasmuch  as  inflammation  was 
the  cause  which  determined  it  in  the  latter,  it  also  produced 
it  in  the  former.*  Among  the  ablest  advocates  of  this 
theory  is  Mr.  Thomas  Bell,  but,  notwithstanding  the  sup- 
port which  it  has  received  from  his  pen,  it  is  opposed  by 
lacts  which  prove  it,  most  conclusively,  to  be  erroneous. 
If  inflammation   of  the   dentinal   structure  of  the   teeth 

*  The  doctrine  of  the  vascularity  of  the  teeth,  as  maintained  bj-  Fox,  was  the 
origin  of  the  theory  in  Ecgland,  that  caries  of  these  organs  resulted  from  inflam- 
mation of  their  dentinal  structure,  but  the  doctrine  had  been  advanced  at  a  much 
earlier  period  in  France.  The  celebrated  French  surgeon,  Ambrose  I'are,  in  treat- 
ing on  tooth-ache,  says,  "these  organs,  after  the  manner  of  other  bones,  suffer  in- 
flammation," and  "quickly  suppurate,  become  rotten,"  etc.,  book  xvii,  chap,  xxv, 
page  387  ;  edition,  1579. 


CAUSES   OF   CARIES.  267 

were  the  cause  of  caries,  the  disease  would  be  as  likely  to 
develop  itself  in  one  part  of  a  tooth  as  another.  The  root, 
the  interior  of  the  crown  between  the  pulp-cavity  and  the 
enamel,  would  as  frequently  be  the  part  first  attacked  as  the 
external  surface.  Now  what  are  the  facts  in  relation  to  this 
matter?  Does  caries  ever  commence  on  the  root  of  a  tooth, 
or  between  the  pulp-cavity  and  the  periphery  of  the  den- 
tine ?     Most  assuredly  not. 

Again,  among  the  causes  which  would  be  most  likely  to 
excite  inflammation  in  these  organs,  are  many  of  the  opera- 
tions performed  for  arresting  the  progress  of  the  disease. 
For  example,  it  is  well  known  that  filing  and  plugging, 
two  of  the  most  valuable  operations  in  dental  surgery,  aug- 
ment, for  a  time  at  least,  the  sensibility  of  the  teeth,  and 
increase  their  susceptibility  to  the  action  of  heat  and  cold — 
agents  regarded  as  among  the  most  frequent  and  powerful 
of  the  exciting  causes  of  inflammation.  Now,  if  caries  of 
the  teeth  were  the  result  of  inflammation,  these  operations, 
instead  of  arresting  the  progress  of  the  disease,  would  cause 
a  recurrence  of  it,  and  hasten  the  destruction  of  those  upon 
which  they  had  been  performed. 

Inflammation  of  the  lining  membrane  of  a  tooth,  may 
end  in  suppuration^  but  we  cannot  believe  that  inflamma- 
tion of  its  dentinal  structure  alone,  causes  a  decomposition 
of  any  portion  of  its  substance.  For  were  such  a  change 
produced  by  any  vital  action,  the  part  deprived  of  vitality, 
would  be  exfoliated^  and  its  loss  repaired  by  the  formation 
of  new  dentine,  which  never  happens  ;  hence,  we  are 
led  to  conclude  that  the  vital  powers  of  the  teeth  are  too 
weak  to  set  up  an  action  capable  of  effecting  the  decompo- 
sition, exfoliation,  or  restoration  of  any  portion  of  their 
substance.  Were  their  living  powers  more  active,  it  is 
probable  their  diseases  would  be  more  analogous  to  those  of 
bones. 

If  inflammation  of  the  dentine,  then,  is  not  the  cause  of 
the  affection,  how  is  the  disease  produced?  This  question 
can  only  be  answered  in  one  way.     It  is  the  result  of  the 


268  CAUSES   OF   CARIES. 

action  of  external  chemical  agents,  and  this  explanation  of 
the  cause  is  not  based  upon  mere  hypothesis.  It  is  supported 
by  facts  that  cannot  be  successfully  controverted.  It  is  well 
known,  that  the  fluids  of  the  mouth,  especially  the  mucous, 
when  in  a  vitiated  condition,  are  capable  of  decomposing 
the  enamel  of  the  teeth  when  not  possessed  of  more  than 
ordinary  density.  The  truth  of  this  assertion  is  demon- 
strated by  the  fact  that  dead  teeth,  and  the  crowns  of  human 
teeth,  or  those  of  animals,  when  employed  as  substitutes  for 
the  loss  of  the  natural  organs,  are  as  liable  to  decay  as 
living  teethj  and  the  decayed  part  in  the  one,  exhibits 
nearly  the  same  characteristics  as  in  the  other.  The  same 
is  true,  too,  with  regard  to  all  artificial  teeth  constructed 
from  bone  of  any  sort,  or  ivory.  Now,  if  the  disease  was 
dependent  upon  any  vital  operation,  neither  dead  teeth  nor 
such  dental  substitutes  as  we  have  mentioned,  would  ever 
decay.  But  inasmuch  as  they  do,  is  it  not  reasonable  to 
suppose  that  the  cause  which  produces  it  in  the  one  case  is 
capable  of  producing  it  in  the  other  ? 

Inflammation  may  influence  the  susceptibility  of  a  tooth 
to  the  action  of  the  causes  which  produce  decay,,  and  even 
the  appearance  of  the  decayed  part,  but  it  is  not  the  imme- 
diate cause  of  the  disease. 

But  it  may  be  asked,  if  caries  be  produced  by  the  action  of 
external  corrosive  agents,  how  is  it  that  the  disease  some- 
times commences  within  the  dentinal  structure  of  a  tooth, 
and  makes  considerable  progress  there,  before  any  indica- 
tions of  its  existence  are  observed  externally?  We  answer, 
that  it  never  does  commence  there ;  its  attacks,  as  we  have 
before  remarked,  are  always  upon  the  external  surface, 
sometimes  upon  the  enamel,  but  most  frequently  upon  the 
dentine  beneath  the  indentations  in  the  grinding  surfaces  of 
the  bicuspids  and  molars,  and  in  the  approximal  sides  of  the 
teeth,  where  this  outer  covering  is  frequently  so  fractured 
by  the  pressure  of  the  organs  against  each  other,  that  the 
secretions  of  the  mouth  find  ready  access  to  the  subjacent 
dentinal  tissue.     Decay  may  be  gradually  going  on  here 


CAUSES  OF   CARIES.  269 

for  months  or  years  without  any  manifest  signs  of  its  ex- 
istence :  and  the  commencement  of  the  disease  in  these 
places  has  led  many  to  suppose  that  it  had  its  origin  within 
the  dentinal  structure. 

A  thorough  investigation  of  this  subject,  ought  to  con- 
vince any  one,  that  caries  always  commences  externally.  If 
it  commenced  in  the  interior  or  within  the  dentinal  sub- 
stance, as  is  asserted  by  some  English  writers,  "the  sphere 
of  usefulness,"  as  is  very  justly  remarked  by  Dr.  Fitch, 
"on  the  part  of  the  surgeon  dentist,"  would  be,  "to  say  the 
least  of  it,  extremely  limited.  For,  if  their  observations," 
alluding  to  those  of  Hunter,  Fox,  Koecker  and  other 
European  writers,  "are  true,  this  disease,  in  its  commence- 
ment, in  one-half  of  the  cases,  is  entirely  out  of  the  reach 
of  medical  aid."  Dr.  F.,  however,  is  of  the  opinion  that 
it  does  sometimes  commence  within  the  substance  of  the 
tooth. 

But  a  still  more  absurd  and  ridiculous  theory  in  regard 
to  the  cause  of  the  disease  is  advanced  by  Mr.  Charles  Bew. 
He  attributes  it  to  the  arrest  of  the  circulation  in  the 
organs,  "by  the  lateral  pressure  of  the  teeth  against  each 
other." 

The  exposure  of  the  teeth,  too,  to  sudden  changes  of  tem- 
perature, as  from  heat  to  cold,  or  cold  to  heat,  has  been 
regarded  almost  from  time  immemorial  as  the  cause  of  their 
decay,  but  no  explanation  of  the  manner  by  which  these 
agents  produced  the  disease  was  attempted,  until  the  pro- 
mulgation of  the  doctrine  that  it  was  the  result  of  inflamma- 
tion, then  they  were  numbered  among  the  exciting  causes. 
The  popular  belief  that  cold  is  a  cause  of  dental  caries,  is 
traced  back  to  Hippocrates,  who,  in  mentioning  the  parts 
of  the  body  injuriously  affected  by  it,  includes  the  teeth.* 

M.  E-ibe  endeavors  to  prove  that  hot  food  is  a  cause  of 
caries,    from  the  fact,  that    "man  is   the  only  animal  ac- 


*  Frigidum  inimicum  ossibus,  dentibus,  nervie,  cerebro,  spinali  meduhe  :  calidum 
varo  utile.    ApTi.  sec.  v. — par.  18. 


2*70  CAUSES   OF   CARIES. 

customed  to  hot  food,  and  almost  the  only  animal  affected 
with  carious  teeth."  Had  this  writer  instituted  a  compari- 
son between  the  teeth  of  man  and  of  brutes,  and  between 
the  solvent  agents  to  which  they  are  respectively  exposed, 
he  might,  doubtless,  have  traced  the  decay  of  the  human 
teeth  to  its  proper  cause. 

"The  Indians  of  North  America,"  says  M.  Tillaeus, 
"knew  nothing  of  the  inconvenience  of  carious  teeth  and 
debilitated  stomachs,  until  after  the  introduction  of  tea 
amongst  them."  From  this,  one  might  suppose  that  tea 
caused  the  teeth  to  decay,  and  that  dyspepsia  was  mainly 
attributable  to  its  use. 

The  decay  of  the  teeth  of  these  people,  since  the  introduc- 
tion of  tea  amongst  them,  may,  however,  be  more  plausibly 
accounted  for.  The  susceptibility  of  these  organs  to  the 
action  of  such  causes  as  produce  the  disease,  have  been 
greatly  increased  by  the  impaired  state  of  their  general  con- 
stitutional health,  occasioned,  since  this  time,  by  the  use  of 
spirituous  liquors,  and  the  luxuries  common  to  civilized  life, 
in  which  they  have  indulged. 

Particular  sorts  of  diet,  too,  such  for  example,  as  animal 
food,  are  said  to  exercise  an  unhealthy  influence  upon  the 
teeth.  In  proof  of  the  assertion,  it  is  stated,  that  Indian 
nations,  who  live  principally  upon  vegetables,  scarcely  ever 
have  a  tooth  to  decay.  But  the  same  may  also  be  said  of 
those  nations  who  subsist  chiefly  on  animal  diet,  and  who 
enjoy  an  equal  degree  of  constitutional  health.  Savage  and 
barbarous  people  usually  have  better  teeth  than  those  of 
civilized  nations,  probably  for  the  reason  that  their  systems 
are  not  enervated  by  luxurious  living.  So  far  as  diet  is 
capable  of  effecting  the  health  of  the  body,  it  may  be  con- 
sidered as  an  indirect  cause  of  caries  ;  for  the  health  of  the 
child  is  not  always  dependent  on  the  health  of  the  parent, 
and  to  the  absence  of  disease  in  the  general  system  during 
childhood,  the  period  when  the  teeth  of  second  dentition 
are  being  formed,  the  soundness  of  the  teeth  of  savages  is 
attributable 


CAUSES   OF   CARIES.  271 

It  is  absurd  to  suppose  that  caries  of  the  teeth  is  attribu- 
table to  the  use  of  animal  food.  It  is  incapable,  even  in  a 
putrid  state,  of  exerting  any  hurtful  action  on  them.  The 
fibres  of  animal  matter  may  be  retained  between  the  teeth 
longer  than  particles  of  vegetable  substance^  and  by  retain- 
ing the  secretions  of  the  mouth  until  they  become  vitiated, 
contribute  indirectly  to  caries  of  these  organs. 

Those  parts  of  the  teeth  which  are  covered  with  thick 
smooth  enamel,  are  rarely,  in  the  first  instance,  attacked 
by  caries.  But  the  chemical  agents  concerned  in  the  pro- 
duction of  the  disease  may  find  access  to  the  dentine  through 
a  fi'acture  or  imperfection  of  the  enamel  scarcely  perceptible 
to  the  naked  eye,  and  hence^  the  disease  is  sometimes  devel- 
oped in  a  part  not  usually  attacked  by  it. 

Mr.  Tomes  believes  that  caries  of  a  tooth  is  always  pre- 
ceded by  loss  of  vitality  in  the  affected  part,  and  that  it  is 
not  until  this  takes  place,  that  the  chemical  agents,  upon 
the  action  of  which  the  structural  alteration  is  produced,  are 
capable  of  afifecting  the  solid  tissues  of  these  organs,  but 
that  this  opinion  is  erroneous  is  proven  by  the  fact,  that  the 
animal  frame-work  of  the  affected  part,  after  the  complete 
decomposition  of  the  earthy  salts,  is  often  so  exceedingly 
sensitive,  that  the  slightest  touch  of  an  instrument  is  pro- 
ductive of  severe  pain,  thus  demonstrating  conclusively  the 
existence  of  remaining  vitality.* 

The  opinion  of  Mr.  Lintott  with  regard  to  the  manner  in 
which  caries  is  produced^  is  founded  upon  the  endosmotic 
phenomena  which  he  thinks  takes  place  in  the  structure  of 
a  tooth.  That  endosmosis  may  take  place  in  the  outer  part 
of  a  tooth  is  possible,  and  if  it  does,  the  secretions  of  the 
mouth,  if  at  all  acidulated,  would  be  likely  to  decompose 
the  calcareous  molecules  with  which  they  are  brought  in 
contact  during  their  imbibition.  But  whether  such  action 
takes  place  or  not,  the  structural  alteration,  beyond  doubt, 
is  produced  by  chemical  agents. 

*  See   Tomeii'  Lecture*  on  Dental  Phyaiology  and  Surgery, 


272  CAUSES  OF  CARIES. 

The  existence  of  an  acid  in  the  mouth,  capable  of  decom- 
posing the  teeth,  is  conclusively  proven  by  Dr.  S.  K.  Mitch- 
ell, in  a  letter  addressed  by  him  to  T.  C.  Hope_,  M.  D.,  of 
Edinburg,  dated  October  10th_,  1*796,  and  the  fact  may  be 
demonstrated  by  a  very  simple  experiment,  which  consists 
in  moistening  a  piece  of  blue  paper,  dyed  with  turnsole, 
with  the  fluids  of  this  cavity,  obtained  from  between  the 
teeth,  where  they  have  been  retained  until  they  have  become 
vitiated.  If  this  be  done,  the  paper  will  be  turned  red.  If, 
then,  these  fluids,  when  in  a  vitiated  condition,  are  possess- 
ed of  acid  properties,  they  must  necessarily  exert  a  deleteri- 
ous action  upon  the  teeth,  by  decomposing  and  breaking 
down  their  calcareous  molecules,  or,  in  other  words,  causing 
their  decay. 

The  acid  detected  by  Dr.  Mitchell  was  the  septic,  (nitrous,\ 
but  the  acetic,  lactic,  oxalic,  muriatic  and  uric  have  been 
detected  in  the  saliva,  in  certain  states  of  the  general  health. 
Donne,  who  has  analysed  the  fluids  of  the  mouth  with 
great  care,  says,  the  saliva,  "in  its  normal  state,"  is  alka- 
line, but  that  "the  secretions  of  the  mucous  membrane  of 
the  mouth  are  acid."* 

It  is  highly  probable,  therefore,  that  the  acids  which  have 
been  detected  in  the  first  of  these  fluids,  may  have  been 
principally  derived  from  the  latter.  Acidity  of  the  saliva 
may,  however,  occur  in  certain  morbid  conditions  of  the 
general  system.  Donne  says,  he  has  observed  it  in  patients 
affected  "with  gastritis,"  "and  in  children  with  aphthae." 
It  is  to  the  action  of  these  acids  upon  those  parts  of  the 
teeth,  where  they  are  long  retained,  that  caries  is  principal- 
ly attributable. 

The  doctrine  that  the  decay  of  tlie  teeth  is  the  result  of 
the  action  of  external  corrosive  agents,  was  first  distinctly 
promulgated  to  the  dental  profession  of  the  United  States, 
about  the  year  1821,  by  Drs.  L.  S.  and  Eleazar  Parmly ; 
and  these  agents  may  consist  of  menstrua,  formed  by  the 

*  Course  de  Jlicroscoj^e,  p.  209. 


CAUSES   OF  CARIES.  273 

decomposition  or  acetous  fermentation  of  the  remains  of 
certain  aliments,  lodged  in  the  interstices  of  the  teeth,  or  of 
the  fluids  of  the  mouth,  especially  the  mucous^  in  a  vitiated 
or  acidulated  condition,  or  of  acids  administered  during 
sickness,  or  used  as  condiments.  According  to  the  tables  of 
elective  attraction,  there  are  but  four  acids,  namely,  the 
oxalic,  sulphuric,  tartaric  and  succinic^  which  precede  the 
phosphoric  in  their  affinity  for  lime.  It  may  hence  be  ar- 
gued, that  none  of  the  other  acids  are  capable  of  decompos- 
ing the  teeth,  or  of  affecting  them  in  any  other  way  preju- 
dicially, but  daily  observation  proves  t  le  erroneousness  of 
this  conclusion.  It  has  been  shown  by  experiment  that  all 
the  acids,  both  vegetable  and  mineral,  act  more  or  less  read- 
ily upon  these  organs.*     But  we  are  disposed  to  believe 


*  The  following  experiments  made  by  Dr.  A.  Westcott,  in  1843,  assisted  by  Mr. 
Dalrymple,  were  repeated  some  years  later,  before  the  class  of  the  Baltimore  Dental 
College. 

"1st.  Both  vegetable  and  mineral  acids  act  readily  upon  the  bone  and  enamel  of 
the  teeth. 

"2d.  Alkalies  do  not  act  upon  the  enamel  of  the  teeth ;  the  caustic  potash  will 
readily  destroy  the  bone  by  uniting  with  its  animal  matter. 

"3d.  Salts  whose  acids  have  a  stronger  affinity  for  the  lime  of  the  tooth,  than 
for  the  basis  with  which  they  are  combined,  are  decomposed,  the  acids  acting  upon 
the  teeth. 

"4th.  Vegetable  substances  have  no  effect  upon  the  teeth  till  after  fermentation 
takes  place,  but  all  of  them,  capable  of  acetic  fermentation,  act  readily  after  this 
acid  is  formed. 

"5th.  Animal  substances,  even  while  in  a  state  of  confined  putrefaction,  act 
very  tardily,  if  at  all,  upon  either  the  bone  or  enamel.  On  examining  the  teeth 
subjected  to  such  influence,  the  twentieth  day  of  the  experiment,  no  visible  phe- 
nomena were  presented,  except  a  slight  deposit  upon  the  surface,  of  a  greenish 
slimy  matter,  somewhat  resembling  the  green  tartar  often  found  upon  teeth  in  the 
mouth. 

"To  give  a  more  definite  idea  of  the  deleterious  agents  to  which  the  teeth  are 
exposed,  and  their  consequent  liability  to  be  affected  by  them,  we  will  notice  the 
effect  produced  by  a  few  of  the  individual  substances,  which  are  more  or  less  liable 
to  be  brought  in  contact  with  the  teeth. 

"Acetic  and  citric  acids  so  corroded  the  enamel  in  forty-eight  hours,  that  much 
of  it  was  easily  removed  with  the  finger  nail. 

"Acetic  acid  or  common  vinegar,  is  not  only  in  common  use  as  a  condiment,  but 
is  formed  in  the  mouth  whenever  substances,  liable  to  fermentation,  are  suffered 
to  remain  about  the  teeth  for  any  considerable  length  of  time. 

"Citric  acid,  or  lemon  juice,  though  less  frequently  brought  in  contact  with  the 
teeth,  acts  upon  them  still  more  readily. 


274  CAUSES   OF   CARIES. 

that  caries  of  the  teeth  results  more  frequently  from  the  ac- 
tion of  some  acid  contained  in  the  mucous  fluids  of  the 
mouth,  than  from  that  of  acid  medicines  or  condiments,  or 
even  from  such  acids  as  may  be  generated  by  the  acetous 
fermentation  of  particles  of  certain  kinds  of  food  lodged  be- 
tween the  teeth.  The  author  is  of  the  opinion,  therefore, 
that  if  all  the  functional  operations  of  the  body  were  always 
healthily  performed,  caries  of  the  teeth  would  seldom  occur, 
for,  in  this  case,  the  alkalinity  of  the  saliva  would  be  suffi- 
cient to  neutralize  the  acidity  of  the  mucous  fluids  of  the 
buccal  cavity,  as  well  as  any  other  acids  generated  in  the 
mouth. 

The  foregoing  theory  of  the  cause  of  dental  caries,  ex- 
plains the  rationale  of  the  treatment  at  present  adopted  for 
arresting  its  progress.  By  the  removal  of  the  decoraiposed 
part  and  filling  the  cavity  with  an  indestructible  material, 
the  contact  of  those  agents,  uj^on  the  chemical  action  of 
which  the  disease  depends,  is  prevented,  and  the  further 
progress  of  the  decay  arrested. 

Among  the  indirect  causes  of  caries,  the  following  may 
be  enumerated:  depositions  of  tartar  upon  the  teeth,  a  fe- 
brile or  irritable  state  of  the  body,  a  mercurial  diathesis  of 
the  general  system,  artificial  teeth  improperly  inserted,  or 
of  bad  materials ;  roots  of  teeth  ;  irregularity  in  the  ar- 
rangement of  the  teeth  ;  too  great  pressure  of  the  teeth 
against  each  other,  and,  in   short,  everything  that  is  pro- 


"Malic  acid,  or  the  acid  of  apples,  in  its  concentrated  state,  also  acts  promptly 
upon  the  teeth. 

"Muriatic,  sulphuric  and  nitric  acids,  though  largely  diluted,  soon  decompose 
the  teeth — these  are  in  common  use  as  tonics. 

"Sulphuric  and  nitric  ethers  have  a  similar  deleterious  eflFect,  as  also  spirits  of 
nitre  — these  are  common  diffusible  stimulants  in  sickness. 

"The  acids  of  some  of  the  salts  also  corrode  the  teeth. 

"Super-tartrate  of  potash,  as  an  example,  destroj-ed  the  enamel  very  readily. 
This  article  is  frequently  used  to  form  an  acidulated  beverage. 

"Raisins  so  corroded  the  enamel  in  twenty-four  hours,  that  its  surface  presented 
the  appearance  and  was  of  the  consistency  of  chalk, 

"Sugar  had  no  effect  till  after  acetous  acid  was  formed,  but  then  the  effect  wa- 
the  same  as  from  this  acid  when  directly  applied." 


PREVENTION   OF   CARTES.  275 

ductive  of  irritation  to  the  alveolo-dental  membrane,  or 
gums. 

The  doctrine  we  have  here  advocated,  is  one  which,  we 
confess,  we  w^ere  for  a  long  time  unwilling  to  believe,  be- 
cause it  was  opposed  to  all  our  earlier  preconceived  notions 
upon  the  subject ;  but  long  and  attentive  observation  has 
forced  us  to  acknowledge  its  truth. 

It  will  be  perceived  from  the  foregoing  exposition  of  the 
causes  of  dental  caries,  that  three  distinct  theories  have 
been  advanced  upon  the  subject,  namely :  1.  The  vital,  as 
advocated  by  Pare,  Fox,  Bell,  and  some  others.  2.  The 
chemical,  as  maintained  by  nearly  all  French  authors,  by 
Salmon,  Drs.  L.  S.  and  E.  Parmly,  and  by  almost  all  late 
writers.  3.  The  chemico-vital,  of  Tomes.  We  might  also 
add  the  endosmotic  tlieory  of  Lintott,  which,  in  fact,  is 
nothing  more  than  an  explanation  of  the  supposed  manner 
in  which  chemical  agents  are  brought  in  more  direct  contact 
with  the  earthy  salts  of  a  tooth. 

PREVENTION   OF   CARIES. 

It  is  an  old  adage,  no  less  true  than  trite,  that  '^an  ounce 
of  prevention  is  better  than  a  pound  of  cure/'  and  in  the 
present  instance  it  may  be  applied  with  its  full  force  ;  and 
were  more  attention  paid  to  the  practical  instruction  thus 
conveyed,  many  of  the  diseases  of  the  teeth  might  be 
avoided. 

Most  of  the  remarks  that  might  be  made  on  this  subject 
have  been  anticipated  ;  consequently,  it  will  only  be  neces- 
sary to  observe,  that  if  the  teeth  are  well  formed,  and  well 
arranged,  all  that  will  be  required,  will  be  to  keep  them 
clean  ;  and  if  any  irregularity  occurs,  it  should  be  remedied 
by  the  means  before  described. 

For  cleansing  the  teeth,  the  regular  and  frequent  use  of 
a  brusli  and  waxed  floss-silk,  will,  in  most  cases,  be  suffi- 
cient. The  enamel  should  be  kept  free  from  all  stains  and 
discolorations,  by  the  employment,  if  necessary,  once  a  day, 


276  TREATMENT   OF  CARIES. 

of  a  dentifrice,  or  what  is  still  better,  an  argillaceous  tooth- 
polisher.  If  a  powder  he  preferred,  either  of  the  following 
may  be  used. 

R  Creta  prep.  §  iv,  pul.  orris  root  §  iv,  pul.  cinnamon 
§  ss,  sup.  carb.  soda  5  ss,  sach.  alb.  §  i,  ol.  lemon  gtt.  15, 
ol.  rose  gtt.  2,  Misce.  R  Cret.  prep.  §  ii,  pul.  orris  root 
§  ii,  prep,  pumice  stone  |  i — Misce. 

These  should  be  reduced  to  an  impalpable  powder,  and 
passed  through  a  sieve,  previously  to  being  used. 

The  importance  of  keeping  the  teeth  clean,  cannot  be  too 
strongly  impressed  upon  the  mind  of  every  individual. 
Proper  attention  to  the  cleanliness  of  these  organs,  contrib- 
utes more  to  their  health  and  preservation  than  is  gener- 
ally supposed.  Against  caries  it  is  a  most  powerful  prophy- 
lactic.. "Where  the  teeth,"  says  Dr.  L.  S.  Parmly,  ""are 
kept  literally  clean,  no  disease  will  ever  be  perceptible. 
Their  structure  will  equally  stand  the  summer's  heat  and 
winter's  cold,  the  changes  of  climate,  the  variation  of  diet, 
and  even  the  diseases  to  which  the  other  parts  of  the  body 
may  be  subject  from  constitutional  causes." 

The  configuration  and  arrangement  of  some  teeth  is  such, 
however,  as  to  preclude  the  possibility  of  keeping  them 
clean,  but  this  should  not  deter  any  one  from  using  the 
proper  means,  for  if  disease  is  not  wholly  prevented,  it  will, 
at  least,  contribute  very  greatly  to  the  preservation  of  the 
organs. 

TREATMENT   OP   CARIES. 

Although  the  physical  condition  of  the  teeth  is  sometimes 
.  such  as  to  render  them  exceedingly  susceptible  to  the  at- 
tacks of  caries,  there  is  no  disease  to  which  the  bod}^  is  lia- 
ble, that  can  be  treated  with  a  more  certain  prospect  of  suc- 
cess than  this.  If  taken  in  time,  it  can  almost  always  be 
arrested ;  and,  if  in  the  majority  of  cases  it  is  not,  it  is  at- 
tributable more  to  want  of  skill  on  the  part  of  the  dentist, 
than  to  the  incurable  nature  of  the  disease.    The  treatment, 


TREATMENT   OF   CARIES.  277 

to  be  effectual,,  must  be  thorough,  and  there  is  no  branch  of 
manual  medicine  that  requires  more  judgment,  or  a  greater 
amount  of  skill,  than  the  one  within  whose  province  the 
treatment  of  the  disease  under  consideration,  comes. 

As  a  general  rule,  before  any  treatment  is  instituted  for 
the  purpose  of  arresting  its  progress,  the  gums  and  alveolo- 
dental  periosteum  should  be  in,  at  least,  a  tolerably  healthy 
condition  ;  for,  if  they  are  inflamed,  or  ulcerated,  or  in  a 
highly  irritable  state  at  the  time,  the  most  skillfully  applied 
remedies  may  prove  unavailing.  If,  therefore,  these  struc- 
tures are  diseased,  such  treatment  as  may  be  necessary  to 
their  restoration,  and  which  will  hereafter  be  described, 
should  first  be  had  recourse  to. 

The  treatment  for  arresting  the  progress  of  caries  consists 
in  two  operations — filing  and  filling.  The  first  is  for  su- 
perficial caries  on  the  lateral  or  approximal  surfaces  of  the 
teeth,  and  as  preparatory  to  the  other,  when  the  disease  is 
situated  in  the  sides  of  the  organs.  The  second  is  for  deep 
seated  caries^  and  the  manner  of  performing  each  will  be 
described  in  the  two  following  chapters. 


CHAPTER     SECOND. 

FILING    TEETH. 

There  is  no  operp^tion  in  dental  surgery,  against  wliicli  a 
stronger  or  more  universal  prejudice  prevails,  tlmn  that  of 
filing  the  teeth  ;  and  when  judiciously  and  skillfully  per- 
formed, there  is  no  one  more  beneficial,  or  effectual  in  ar- 
resting the  progress  of  caries.  Thousands  of  teeth  are 
every  year  rescued  from  its  ravages,  and  preserved  through 
life,  by  it.  But,  although  it  is  productive  of  so  much  good, 
it  is  also,  in  the  hands  of  ignorant  and  unskillful  operators, 
productive  of  incalculable  injury. 

With  regard  to  the  merits  of  this  wrongly  judged  and 
much  abused  operation,  the  author's  views  are  so  fully  ex- 
pressed by  the  late  Dr.  John  Harris,  in  a  paper  published 
in  the  September  No.  of  vol.  5,  of  the  American  Journal  of 
Dental  Science,  tliat  he  cannot  do  better  than  quote  his  re- 
marks upon  the. subject. 

He  says,  "Filing  the  teeth  is  one  of  the  most  important 
and  valuable  resources  of  the  dental  art ;  it  is  one  that  has 
stood  the  test  of  experience,  and  is  of  such  acknowledged 
utility,  as  to  constitute  of  itself,  in  the  treatment  of  super- 
ficial caries  on  the  lateral  surfaces  of  the  teeth,  one  of  the 
most  valuable  operations  that  can  be  performed  on  these  or- 
gans. And  even  after  caries,  in  the  localities  just  men- 
tioned, has  progressed  so  far  as  to  render  its  removal,  by 
this  means,  impracticable  or  improper,  the  use  of  the  file, 
in  most  cases,  is  still  necessary,  in  order  to  the  successful 
employment  of  other  remedial  agents.  But  in  cither  case, 
a  failure  to  accomplish  the  object  for  which  it  is  used,  would 
only  be  equivalent  to  doing  nothing  at  all. 


FILING   TEETH.  279 

^'Tlie  use  of  the  file,  then,  may  very  justly  be  considered 
a  sine  qua  non,  for  the  i-emoval  of  superficial  caries  from  the 
sides  of  the  teeth  which  come  in  contact  with  each  other,  as 
can  be  attested  by  thousands  of  living  witnesses,  and  in  pre- 
paring the  way,  in  deep-seated  caries,  for  the  thorough  re- 
moval of  the  disease,  and  filling,  successfully^  the  cavity 
thus  formed. 

"In  a  paper  written  by  myself,  some  eleven  or  twelve 
years  ago^  upon  this  subject,  I  contended  that  filing  the 
teeth  was  not  necessarily  productive  of  caries^  and  my  sub- 
sequent exj)erience  and  observations  have  only  tended  to 
confirm  the  correctness  of  the  opinion  which  I  then  ad- 
vanced^ and  I  cherish  the  belief  that  this  opinion  will  not, 
at  this  time,  conflict  with  the  views  of  the  more  enlightened 
of  my  professional  brethren. 

'^But  when  reference  is  had  to  the  physical  2)eculiarities 
of  the  teeth,  it  will  at  once  be  perceived,  that  they  present 
a  strange  departure  from  the  laws  that  govern  and  control 
all  other  parts  of  the  body — that  these  organs,  when  dis- 
eased, can  only  be  restored  to  health  and  usefulness  by  art, 
unaided  by  the  sanitary  powers  of  nature.  Hence  it  is, 
that  most  of  the  operations  upon  them,  will  not,  like  those 
in  general  surgery,  admit  of  mediocrity  in  their  perform- 
ance. 

"The  fact  that  the  crowns  of  the  teeth  are  covered  with 
enamel,  is  alone  sufficient  evidence  of  its  importance  and 
utility  in  shielding  and  protecting  the  bony  structure  which 
it  envelops,  from  mechanical  and  morbid  influences,  so  that 
it  would  seem  that  its  removal  or  loss  would  necessarily  ex- 
pose the  organs  to  certain  destruction.  But  we  have  satis- 
factory evidence,  tliat  teeth,  alter  having  suffered  the  loss  of 
large  portions  of  the  enamel,  have  been  restored  to  health, 
and  preserved  for  many  years,  and  often  through  life. 

"The  rapidity  witli  which  caries  of  the  teeth  progress, 
after  the  exposure  of  the  bone,  by  the  loss  of  the  enamel, 
depends  upon  the  physical  peculiarities  of  the  organs,  and 


280  FILING  TEETH. 

upon  local  and  constitutional  influences ;  hence  the  difficul- 
ty, and  oftentimes  impossibility  of  obtaining  the  object  for 
which  dental  operations  are  instituted,  while  such  influ- 
ences are  suffered  to  exist.  If  special  regard  is  not  had  to 
the  curative  indications,  most,  if  not  all  the  operations  upon 
the  teeth_,  which  have  for  their  object  their  ultimate  preser- 
vation, are  sure  to  a  greater  or  less  extent,  to  augment  all 
of  the  previously  existing  local  affections,  by  increasing  the 
irritability  of  the  parts,  and  by  rendering  them  more  sus- 
ceptible of  being  acted  upon  both  by  local  and  constitu- 
tional causes, 

"Without  indulging  in  further  prefatory  remarks,  I  shall 
proceed  to  notice  more  particularly  the  subject  under  consid- 
eration. And  I  would  observe,  firstly,  that  an  experience 
obtained  from  twenty-three  years'  constant  practice,  has 
fully  convinced  me,  not  only  of  the  propriety,  but  of  the  ab- 
solute necessity  in  the  treatment  of  caries  in  the  lateral  sur- 
faces of  the  teeth,  of  employing  the  file.  There  is  no  instru- 
ment so  well  adapted  as  this  for  the  removal  of  the  disease 
when  situated  in  these  parts  of  the  teeth^  and  especially, 
when  the  organs  are  in  close  proximity  with  each  other,  or 
for  the  removal  of  rough  and  weakened  edges  of  the  enamel 
in  deep-seated  caries,  and  for  making  sufficient  space  or 
room  for  the  removal  of  the  diseased  parts  preparatory  to 
plugging, 

"It  may  be  laid  down  as  a  rule,  from  which  exceptions 
should  never  be  taken,  that  the  file  should  not  be  used, 
while  the  teeth  or  their  contiguous  parts  are  suff'ering  gen- 
eral or  local,  acute  or  chronic,  inflammation.  Therefore, 
when  this  is  the  case,  the  treatment  of  the  general  and  lo- 
cal aifections  should  be  precedaneous  to  the  operation  of 
filing.  Upon  the  removal  of  all  the  acute  or  chronic  dis- 
eases of  the  mouth,  the  success  of  the  dentist  in  the  treat- 
ment of  affections  of  the  teeth,  calling  for  the  emj^loyment 
of  the  file,  greatly  depends.  As  much  importance,  there- 
fore, is  to  be  attached  to  an  enlightened  and  discriminating 
judgment,  as  to  tact  in  the  performance  of  the  operation. 


FILING  TEETH.  281 

"In  fact  the  removal  of  all  local  causes  of  irritation,  such 
as  all  dead  roots  of  teeth,  teeth  occasioning  alveolar  ab- 
scesses, or  such  as  exert  a  morbid  influence  upon  the  sur- 
rounding parts,  and  all  depositions  of  salivary  calculus  or 
other  foreign  matter,  should  always  precede  all  other  opera- 
tions upon  these  organs. 

"The  length  of  time  necessary  for  the  restoration  of  the 
parts  contiguous  to  the  teeth,  may  vary  from  a  few  days,  or 
weeks,  to  months,  depending  upon  the  nature  and  extent  of 
the  disease,  the  general  health  of  the  patient,  and  the  con- 
stitutional as  well  as  local  treatment  to  which  they  are  sub- 
jected. 

"But,  in  assuming  the  position,  that  filing  the  teeth  does 
not,  of  necessity,  cause  them  to  decay,  it  is  by  no  means  to 
be  inferred,  that  the  oj^eration  can,  in  all  cases,  and  under 
all  circumstances,  be  performed  with  advantage  or  even 
impunity.  By  no  means  ;  its  effects,  like  those  of  most 
other  operations  uj^on  the  teeth,  when  the  curative  indica- 
tions are  disregarded,  or  not  properly  carried  out,  are  never 
passive.  The  employment  of  the  file  at  an  improper  time, 
and  in  an  improper  manner,  increases  the  liability  of  the 
teeth  to  decay,  and  augments  the  irritability  of  all  the 
parts  adjacent  to  them,  and  consequently  their  suscepti- 
bility of  being  acted  upon  by  local  and  constitutional 
causes. 

"The  principal,  and  I  believe,  only  objection,  urged 
against  filing  the  teeth,  is  based  upon  the  erroneous  belief, 
that  the  loss  of  any  part  of  the  enamel  of  these  organs 
must  necessarily  result  in  their  destruction.  But,  if  this  be 
true,  why  is  it,  as  I  have,  on  another  occasion,  asked,  that 
the  negroes  of  Abyssinia  have  such  sound  teeth  as  they  are 
represented  to  have,  since  it  has  long  been  a  custom  with 
them  to  file  all  their  front  teeth  to  points,  so  as  to  make 
them  resemble  the  teeth  of  a  saw  or  those  of  carnivorous 
animals.  Of  course,  large  portions  of  the  enamel  and  con- 
siderable of  the  bony  structure,  must  be  removed  in  the 
operation,  and  yet,  we  are  credibly  informed  that  their  teeth 
19 


282  FILING  TEETH, 

seldom  decay.  The  same  may  be  said  of  the  Brahmins  of 
India,  who,  from  remote  ages,  have  been  in  the  habit  of 
using  the  file,  principally,  I  believe,  for  separating  their 
teeth_,  and  they,  too,  are  noted  for  having  fine  teeth.  I 
might  refer  to  the  people  of  other  countries,  with  whom  the 
same  practice  has  long  had  an  existence^  but  it  is  not  neces- 
sary to  go  abroad  for  proof,  when  we  have  such  an  abun- 
dance of  it  at  home,  to  establish  the  propriety  and  absolute 
necessity  for  the  practice  I  am  now  advocating. 

"With  the  people  just  referred  to,  it  is  evident  that  they 
file,  principally,  for  the  purjDose  of  ornamenting  their  teeth, 
but  with  us,  only  as  a  remedial  agent  in  the  treatment  of 
their  diseases.  The  reason  why  their  teeth  are  not  so  sub- 
ject to  disease  as  are  those  of  the  inhabitants  of  civilized 
countries,  is  attributable  to  the  difference  in  their  habits  of 
life,  modes  of  living,  and  the  absence  of  the  causes  pro- 
ductive of  the  various  diseases  peculiar  to  civilization  and 
refinement. 

''But  notwithstanding  the  utility  and  value  of  the  opera- 
tion, filing  the  teeth  may  be  regarded  as  a  predisposing 
cause  of  caries.     But  if  this  be  true^  it  may  be  asked,  why 
file  at  all  ?     I  answer,  in  this  country,  owing  to  the  preva- 
lence of  the  immediate  or  direct  cause  of  caries,  the  opera- 
tion is  only  performed  as  remedial,  for  the  purpose  of  remov- 
ing actual  disease  or  as  preparatory  to  plugging.     It  does 
not,  of  necessity,  follow,  that  caries  of  the  teeth,  after  hav- 
ing been  judiciously  removed  or  treated,  although  the  or- 
gans be  predisposed  to  the  disease,  should  ever  again  occur. 
The  general  system  often  escapes  the  development  of  the  dis- 
eases to  which  it  is  predisposed  through  life,  so,  also,  do 
the  teeth.     If  the  operation  be  properly  performed,  and  the 
filed  surfaces  kept  thoroughly  clean,  a  recurrence  of  the  dis- 
ease, notwithstanding  the  increased  predisposition  thus  in- 
duced, will  never  again  take  place.     The  immediate  cause 
of  dental  caries  being  the  contact  of  corrosive  agents  with 
the  teeth,  the  necessity  for  this  precaution  is  obvious.     The 
bony  structure  of  these  organs  is  more  easily  acted  apon  by 


FILING   TEETH.  283 

sucli  causes,  than  the  enamel,  and  for  this  reason,  when  it 
becomes  necessary  to  expose  it,  with  a  file,  for  the  removal 
of  disease,  sliould  be  done  in  such  a  way  as  to  admit  of  its 
being  kept  thoroughly  and  constantly  clean,  so  that  if  it 
afterwards  becomes  carious,  it  will  be  owing  altogether  to 
the  inattention  of  the  patient.  In  view  of  this,,  whenever  it 
becomes  necessary  to  file  the  teeth,  whether  for  the  complete 
removal  of  caries,  or  as  only  preparatory  to  plugging,  we 
should  always  imj)ress  upon  the  patient  the  importance  of 
attending  to  this  matter — of  cleansing  the  surfaces  thus  ope- 
rated upon,  at  least  three  or  four  times  every  day.  The 
future  preservation  of  the  organs,  and  especially  when  they 
are  of  a  soft  or  chalky  texture,  for  they  are  then,  by  far, 
more  easily  acted  upon  by  decomposing  agents  than  when 
hard,  will  depend  upon  the  constant  and  regular  observance 
)of  this  precaution. 

"Tlie  cases  requiring  the  use  of  the  file  vary  so  much, 
that  it  would  be  difficult  to  lay  down  precise  directions  with 
regard  to  the  extent  to  which  the  operation  should  always 
be  carried.  This  must  be  determined  by  the  judgment  of 
the  operator. 

"The  object  for  which  the  operation  is  performed,  may 
be  defeated  either  by  filing  too  much  or  too  little.  Either 
extreme  should  be  avoided,  but  I  am  of  the  opinion,  that 
by  far  the  greater  number  uf  unsuccessful  results  are  at- 
tributable, rather  to  the  too  moderate,  than  to  the  too 
great  use  of  this  instrument,  and  especially,  where  the  cir- 
cumstances of  the  case  have  nothing  to  do  in  determining 
the  result. 

"But  it  is  not  my  object  to  describe  the  manner  in  which 
teeth  should  be  filed,  but  merely  to  offer  a  few  general  re- 
marks on  the  advantages  that  result  from  it  when  the  ope- 
ration is  judiciously  performed,  and  to  show  that  it  is  from 
the  abuse  of  the  use  of  the  file,  in  the  hands  of  the  ignorant 
and  inexperienced  practitioner,  that  its  merits  have  been  so 
frequently  erroneously  estimated. 

"It  will  be  perceived  from  the  foregoing  remarks,  that  its 


284  FILING   TEETH. 

utility  depends  upon  carrying  out  all  the  curative  indica- 
tions, that  it  should  never  be  resorted  to  except  in  the 
absence  of  disease  in  the  parts  with  which  these  organs  are 
immediately  connected.  Therefore,  to  estimate  the  merits 
of  the  operation,  correctly,  we  should  know  all  the  circum- 
stances under  which  it  has  been  performed,  the  competency 
of  the  operator,  and  whether  he  was  permitted  the  free  ex- 
ercise of  his  judgment. 

''The  dentist  is  often  called  upon  to  render  his  services, 
where,  from  the  timidity  or  ignorance  of  his  patient,  he  is,  if 
he  consents  to  operate  at  all,  so  restricted  in  the  application 
of  his  remedies,  that  but  little,  if  anything  more  than  tem- 
porary relief  can  be  afforded.  And  cases  may  occasionally 
occur,  in  which,  from  unforeseen  circumstances,  even  after 
the  most  skillful  management,  the  dentist  may  be  disap- 
pointed in  his  expectations,  and  fail  in  the  attainment  of 
the  object  for  which  his  services  were  solicited." 

To  secure  the  success  of  the  operation,  it  is  sometimes  ne- 
cessary to  file  away  a  considerable  portion  of  the  tooth,  but 
in  doing  this,  the  operator  should  be  careful  not  to  destroy 
the  symmetry  of  the  labial  surface.  The  aperture,  ante- 
riorly, should  only  be  wide  enough  to  admit  of  a  free  oblique 
or  diagonal  motion  of  a  safe-sided  file  of  about  one-fourth  of 
a  line  in  thickness.  In  this  way,  one-fourth  or  more  of  a 
tooth  may  be  removed  without  materially  altering  its  ex- 
ternal appearance.  But  a  tooth  should  not  be  filed  entirely 
to  the  gum ;  a  projection  should  be  left  to  prevent  the  ap- 
proximation of  it  and  the  adjoining  organ. 

When  the  decay  occupies  a  large  portion  of  tlie  approxi- 
mal  surface,  and  has  penetrated  into  the  tooth  to  a  consider- 
able depth,  and  destroyed  the  enamel  anteriorly,  causing  it 
to  present  a  ragged  and  uneven  edge,  it  will  be  necessary  to 
form  a  wider  exterior  aperture  than  correct  taste  would 
dictate.  When  the  approximal  surfaces  of  the  two  front 
teeth  are  affected  with  caries,  about  an  equal  portion, 
if  circumstances  will  permit,  should  be  filed  from  each 
tooth. 


FILING  TEETH.  285 

The  accompanying  engraving  rep-  Fio.  71. 

resents  a  front  view  of  the  superior 
incisors  and  cuspid ati  after  having 
been  filed. 

It  is  scarcely  necessary  to  give  any  directions  with  regard 
to  the  manner  of  holding  the  file.  In  filing  the  front  teeth 
and  those  on  the  right  side  of  the  jaws,  the  operator  should 
stand  at  the  right  and  a  little  behind  the  patient,  in  order 
to  steady  his  head  as  it  rests  against  the  head-piece  or  top 
of  the  back  of  the  operating  chair,  with  his  left  arm,  while 
with  the  fingers  of  the  hand  of  the  same^  the  lips  are 
raised  and  the  teeth  properly  exposed  for  the  operation.  In 
filing  the  teeth  on  the  left  side  of  the  mouth,  it  will  be  ne- 
cessary for  the  operator  to  stand  upon  the  same  side  of  his 
patient.  The  file,  firmly  grasped  between  the  thumb  and 
middle  finger  of  the  right  hand,  with  the  end  of  the  fore- 
finger resting  upon  the  edge  of  its  distal  extremity,  should 
be  moved  backwards  and  forwards  in  a  direct  line,  as  any 
deviation  from  this  would  immediately  snap  the  instrument. 
The  first  opening  between  the  teeth,  when  the  aj)proximal 
edges  of  the  two  are  carious,  should  be  made  with  a  flat  file, 
of  about  one-fourth  of  a  line  in  thickness,  cut  on  both  sides 
and  both  edges ;  this  done,  a  file  cut  only  on  one  side  and 
both  edges,  should  be  employed  for  the  completion  of  the 
operation.  If  but  one  tooth  is  decayed,  the  operation  may 
be  commenced  and  completed  with  a  safe-sided  file.  The 
file,  during  the  operation,  should  be  frequently  dipped  in 
water,  to  prevent  it  from  becoming  heated  or  choked  be- 
tween the  teeth. 

After  a  sufficient  portion  of  the  tooth  has  been  filed  away, 
the  surface  should  be  made  as  smooth  as  possible  with  a 
very  fine  or  half  worn  file,  or  Arkansas  oil-stone,  and  a 
burnisher.  The  edges  and  sharp  corners  should  be  rounded 
and  made  smooth,  and  when  the  operation  is  completed, 
the  patient  should  be  directed  to  keep  the  filed  surfaces  per- 
fectly clean,  for  if  the  mucous  secretions  of  the  mouth,  or 


286 


FILING   TEETH. 


Fig.  72. 


extraneous  matter  is   permitted  to  adhere  to  tliem,  a  recur- 
rence of  the  disease  will  take  place. 

In  separating  the  bicuspids,  an  aperture  should  be  made 
somewhat  in  the  form  of  the  letter  V;  it  should  not,  how- 
ever, form  an  acute  angle  at  the  gum  ;  and  for  its  formation 
a  file,  shaped  like  the  pinion-file  of  a  clock,  or  one  that  is 
oval  on  one  side  and  flat  on  the  other,  will  be  found  most 
suitable.  An  aperture,  shaped  like  this,  will  prevent  the 
approximation  of  the  sides  of  the  teeth,  and  if  filling  be 
necessary,  it  will  enable  the  oj^erator  to  do  it  in  the  most 
perfect  manner. 

In  Fig.  72  is  represented  a 
posterior  view  of  the  superior 
incisors  and  cuspidati  after 
having  been  filed;  also,  a  ver- 
tical view  of  the  bicuspids  and 
molars  after  having  been  sub- 
jected to  the  same  operation. 
When  the  separation  of  the 
molar  teeth  becomes  necessary, 
the  same  shaped  aperture  should 
be  formed.  But  as  these  teeth 
are  situated  so  far  back  in  the  mouth,  it  cannot  often  be 
done  with  a  straight  file,  and  to  obviate  the  difficulty,  an 
instrument,  with  which  every  dentist  is  acc[uainted,  denom- 

(^G.  73. 


inated  a  file  carrier,  is  usually  employed.  But,  in  conse- 
quence of  the  difficulty  of  procuring  instruments  of  this 
kind,  exactly  suited  to  holding  files  of  the  right  shape,  the 


FILING  TEETH.  287 

autlior,  a  few  years  ago,  constructed  some  file  patterns  for 
this  purpose,  and  through  Messrs  Canfield  &  Brothers,  of 
Baltimore,  sent  them  to  Stub's  manufactory,  in  England, 
and  had  files  made,  which  he  found  to  answer  his  fullest 
expectations. 

These  files,  as  may  be  seen  by  the  foregoing  cut,  are  shaped 
something  like  the  pinion  file  of  a  clock :  they  are  an  inch 
and  a  half  long,  and  have  a  handle  of  about  six  inches  in 
length,  bent  in  such  a  manner  that  the  instrument  may  be 
used  between  the  molar  teeth  without  interfering  with  the 
corners  of  the  mouth.  These  files  are  in  pairs — one  for  the 
right  and  one  for  the  left  side  of  the  mouth.  But,  in  Fig. 
73,  two  patterns  are  represented.  The  upper,  in  conse- 
quence of  the  handle  being  on  a  line  with  the  file,  works 
more  easily  than  the  lower  one. 

Fig.  74. 


^u^ffnp|/m'iii?fifg!TnfhiiiiPi'j* 


=— T^ 


Fig.  74,  represents  a  very  useful  and  valuable  file-carrier 
invented  by  Dr.  A.  Westcott.  It  is  so  constructed  that  the 
handle  is  brought  on  a  line  with  the  file — consequently  two 
are  required,  one  for  each  side  of  the  mouth. 

Fig.  74.  The  portion  marked  c,  is  a  spring,  and  through  the  arms  a  and  b,  there 
are  square  mortices,  to  receive  the  ends  of  the  file  and  to  keep  it  from  turning.  It 
will  be  perceived,  by  examining  the  cut,  that  the  arm  6  does  not  come  ofif  at  right 
angles,  and  the  object  of  this  shape  must  be  apparent.  The  file  is  prepared  by- 
making  each  end  square,  corresponding  with  the  size  of  the  mortices  in  the  arms, 
and  is  adjusted  to  the  carrier  by  first  putting  one  end  of  the  file  into  the  arm  a, 
and  pressing  down  the  other  end  into  the  mortice  b,  the  spring  constituting  that 
portion  of  the  instrument  between  the  arm,  which  yields  sufficiently  to  admit  of 
this.  It  will  be  readily  perceived  that  the  file  may  be  easily  taken  out,  while  it 
could  not  well  be  thrown  in  an  opposite  direction ;  also,  that  the  arm  a  sustains 
almost  the  entire  strain  made  upon  the  instrument;  the  arm  6  serving  to  steady 
the  file,  which  is  represented  to  the  left  of  the  detached  portion  of  the  instrument, 
marked  a,  b  and  c. 


CHAPTER    THIRD. 

FILLING  TEETH. 

This  is  one  of  the  most  difficult  operations  the  dentist  is 
called  upon  to  perform — it  often  baffles  the  skill  of  operators 
who  have  been  in  practice  many  years.  It  is,  alsOj  when  well 
performed,  the  most  certain  and  only  remedy  that  can  be  ap- 
plied for  arresting  the  progress  of  deep-seated  caries.  But  to 
be  effective,  it  must  be  executed  in  the  most  thorough  and 
perfect  manner.  The  preservation  of  a  tooth,  may  be  re- 
garded as  certain,  when  well  filled,  and  with  a  suitable  mate- 
rial, if  it  be  afterwards  kept  constantly  clean.  At  any  rate, 
it  will  never  again  be  attacked  by  caries  in  the  same  place. 

On  this  highly  important  operation.  Dr.  E.  Parmly  thus 
remarks — "If  preservation  is  as  good  as  a  cure_,  this  is  as 
good  as  both,  for  the  operation  of  stopping,  when  thoroughly 
performed,  is  both  preservation  and  cure.  And  yet,  it  must 
never  be  forgotten,  that  this  assertion  is  true  only  in  those 
instances  in  which  the  operation  is  well  and  properly  done ; 
and,  perhaps,  it  is  imj)erfectly  and  improperly  performed 
more  frequently  than  any  other  operation  on  the  teeth. 

"There  are  reasons  for  this  fact,  into  which  every  ambi- 
tious and  honorable  practitioner  will  carefully  inquire. 

'■'Although  the  books  are  explicit  on  this  point,  I  deem  it 
sufficiently  important  to  deserve  a  few  additional  remarks, 
and  yet  I  am  perfectly  aware  that  my  time  requires  me  to  be 
extremely  general  in  my  observations.  Let  me  say,  then, 
that  the  following  considerations  are  essential,  and,  therefore 
indispensable  to  success  in  this  department  of  practice. 

"Firstly — The  instruments  used  must  be  of  the  proper 
construction  and  variety. 


FILLING  TEETH.  289 

^^ Secondly — The  metal  employed  must  he  properly  prepar- 
ed as  well  as  properly  introduced. 

^^ Thirdly — The  cavity  which  receives  the  metal,  must  be 
so  fitted  as  to  retain  it  in  such  a  manner  as  to  exclude  not 
only  solids,  but  all  fluids,  and  even  the  atmosphere  itself. 

^^ Fourthly — The  surface  of  the  metal  must  be  left  in  such 
condition  as  to  place  it  beyond  the  reach  of  injury  from  food 
and  other  mechanical  agents  with  which  it  must  of  necessity 
come  in  contact. 

^^ Fifthly — The  tooth  thus  stopped  should  be  free  from 
pain,  and  every  known  cause  of  internal  inflammation." 

It  is  important,  however,  that  the  operation  be  performed 
before  the  disease  has  reached  the  pulp  cavity ;  after  this,  the 
permanent  preservation  of  the  tooth  in  many  cases  may  be 
regarded  as  more  or  less  questionable.  Still,  under  favora- 
ble circumstances,  the  author  believes  it  may  in  the  majori- 
ty of  cases^  be  performed  with  success.  But,  as  the  propri- 
ety and  manner  of  filling  a  tooth  after  the  pulp  has  become 
exposed,  will  hereafter  come  up  for  special  consideration,  as 
well,  also,  as  the  operation  of  filling  the  pulp  cavity  after 
the  destruction  of  the  pulp,  it  will  not  be  necessary  to  en- 
large upon  these  subjects  at  this  time. 

A  tooth  is  sometimes  exceedingly  sensitive  when  the 
nerve  is  not  exposed ;  but  this  need  not  deter  the  operator 
from  removing  the  decayed  part  and  filling  the  cavity,  as 
the  only  inconvenience  it  will  occasion  the  patient,  will  be 
a  little  suffering  during  the  operation,  and  slight  momenta- 
ry pain  for  a  few  days,  whenever  any  thing  hot  or  cold  is 
taken  into  the  mouth.  But  when  the  sensibility  is  so  great 
that  the  patient  cannot  bear  the  removal  of  the  diseased 
part — a  thing  which  very  rarely  occurs,  it  may  be,  in  most 
cases,  obtained  by  the  api^lication  of  chloride  of  zinc,  to  the 
cavity  of  the  tooth  for  from  three  to  six  minutes.  When 
this  is  done,  care  should  be  taken  to  prevent  it  from  coming 
in  contact  with  any  of  the  soft  parts  of  the  mouth.  The 
fortieth  or  fiftieth  part  of  a  grain  of  arsenic  is  sometimes  ap- 
plied, but  there  is  great  danger  of  destroying  the  vitality  of 


290  MATERIALS   EMPLOYED   FOR   FILLING   TEETH. 

the  pulp  by  the  use  of  this  agent^  even  though  it  be  permit- 
ted to  remain  but  for  a  few  hours.  Cobalt,  it  is  said,  is 
less  dangerous  and  equally  efficacious. 

Filling  teeth,  is  advisable  only  under  certain  circumstan- 
ces, and  when  the  operation  is  performed  without  due  re- 
gard to  these,  it  may  be  productive  of  injury  rather  than 
benefit. 

MATERIALS  EMPLOYED  FOR  PILLING  TEETH. 

Among  the  articles  which  have  been  employed  for  filling 
teeth,  are,  gold,  tin,  lead,  gum  mastic,  silver,  an  alloy  of 
bismuth,  tin  and  lead,  amalgam,  and  platina. 

Gold  Foil. — To  the  use  of  this  material,  when  properly 
prepared,  there  is  no  objection.  It  is  the  only  one,  in  the 
opinion  of  the  author,  which  should  ever  be  employed  for 
filling  teeth.  No  better  material  is  wanted  for  the  opera- 
tion. A  tooth,  in  almost  every  case,  may  be  so  filled  with 
it  as  to  secure  its  permanent  preservation.  It  should,  how- 
ever, be  perfectly  pure,  be  beat  into  thin  leaves,  and  well 
annealed  before  it  is  used.  When  prepared  in  this  manner, 
it  may  be  pressed  into  all  the  inequalities  of  the  cavity,  and 
rendered  so  firm  and  solid  as  to  be  impermeable  to  the  fluids 
of  the  mouth.* 

Although  there  may  be  no  difierence  in  the  purity  of  the 
gold,  and  the  thickness  of  the  leaves,  yet  a  marked  and 
great  difference  will  be  found  to  exist  in  the  malleability 
and  toughness  of  the  foil  of  different  beaters.  The  art  of 
preparing  gold  for  filling  teeth  is  an  exceedingly  nice  and 
difficult  one,  and  is  believed  has  attained  greater  perfec- 

*  It  would  seem  from  what  Fauchard  says  upon  the  subject,  {Le  Chirurgien  Den- 
tiate,  tome  2,  pp.  68  to  70,)  that  this  metal,  to  some  extent  at  least,  has  been  used 
for  filling  teeth  for  a  long  time.  Although  he  gives  the  preference  to  tin  and  lead, 
on  account  of  the  greater  malleability  of  these  metals,  he  speaks  of  gold  as  being 
used  by  other  dentists.  But  the  operation  of  filling  teeth,  at  the  time  this  au- 
thor wrote,  was  very  imperfectly  understood,  and  the  gold  then  employed  for  the 
purpose  must  have  been  so  badly  prepared  as  to  render  its  use  exceedingly  difiicult. 


MATERIALS  EMPLOYED   FOR   FILLING  TEETH.  291 

tion  ill  tlie  United  States  than  any  other  country ;  or,  at 
any  rate,  this  fact  is  so  generally  admitted,  that  many  of 
the  most  eminent  European  practitioners  procure  most  if 
not  all  they  use,  from  Mr.  Charles  Abbey,  of  Philadelphia, 
the  oldest  manufacturer  in  America.  There  are,  however, 
many  other  gold  beaters  in  the  United  States  who  manufac- 
ture gold  foil  of  a  very  excellent  quality. 

The  thickness  of  the  leaves  is  determined  by  the  number 
of  grains  each  contains,  and  is  designated  by  numbers  on 
the  books,  between  the  leaves  of  which  they  are  placed,  af- 
ter having  been  properly  annealed.  These  vary  from  4  to 
20.  For  example,  a  book  containing  a  quarter  of  an  ounce 
of  No.  4,  will  have  thirty  leaves  in  it.  The  weight  of  the 
leaves,  generally,  vary  two  grains,  so  that  the  numbers 
run,  4,  6^  8,  10,  and  so  on  up  to  20.  Some  dentists,  in 
their  practice,  use  foil  varying  in  Nos.  from  4  up  to  20, 
while  others  confine  themselves  to  a  single  No.  If  but  one 
No.  be  used,  4  will,  perhaps,  be  found  better  than  any 
other.  The  author  has  used  Nos.  4,  6,  8,  10  and  15,  but 
he  prefers  the  first,  and  is  decidedly  of  opinion,  that  in  a 
large  majority  of  cases^  a  better  filling  can  be  made  with  it 
than  any  of  the  others.  There  may  be  cases  in  which 
higher  Nos.  can  be  more  advantageously  employed. 

Foil  manufactured  from  sponge  or  crystalline  gold_,  is  so 
adhesive^  that  any  number  of  pieces  may  be  welded  one  to 
another,  and  by  means  of  which,  a  part,  or  even  the  whole 
of  the  crown  of  a  tooth,  may  be  built  up  with  it.  The 
same  properties  may  also  be  imparted  to  foil  manufactured 
in  the  ordinary  way,  by  re-annealing.  This  property  is  pe- 
culiarly valuable  in  many  cases  where  it  becomes  necessary 
to  build  up  a  large  portion  of  the  crown  of  a  tooth ;  but 
when  it  is  used,  instruments  having  integrating  points  are 
required,  like  those  employed  in  the  use  of  crystalline  gold. 
But  for  filling  ordinary  cavities  in  teeth,  this  property  is 
of  no  advantage  ;  indeed,  for  filling  a  deep  cavity,  having 
an  orifice  no  larger  than  the  bottom,  it  is  objectionable,  as 
more  time  and  labor  is  required  to  reach  the  same  point  of 


292  MATERIALS  EMPLOYED  FOR  FILLING  TEETH. 

excellence  with  it,  than  with  foil  such  as  is  usually  obtained 
from  the  best  manufacturers.* 

Sponge  and  Crystalline  Gold  have  recently  been  employed 
by  a  few  dentists  for  filling  teeth,  and  although  the  antici- 
pations of  the  profession  generally  have  not  been  fully 
realized  by  these  preparations,  the  experiments  thus  far 
warrant  the  belief  that  the  last,  at  least,  may  be  so  im- 
proved, as  to  render  it  an  exceedingly  valuable  acquisition 
to  dental  practice.  The  author  has  used  it  in  a  number  of 
cases  with  very  satisfactory  results. 

Since  the  publication  of  the  fifth  edition  of  this  work,  the 
properties  of  crystalline  and  sponge  gold  have  been  more 
thoroughly  and  extensively  tested,  and  the  result  of  subse- 
quent experience,  taken  in  the  aggregate,  especially  with  the 
last  named  preparation,  has  fully  confirmed  the  favorable 
opinion,  expressed  in  the  preceding  paragraph,  with  regard 
to  its  value.  Those  who  have  had  most  experience  in  the  use 
of  it,  say  it  is  superior,  in  many  cases,  to  foil.  The  author 
is  acquainted  with  several,  and  they  among  the  most  skill- 
ful operators  in  the  United  States,  who  have  used  it  almost 
exclusively  in  their  practice,  for  more  than  a  year  ;  and  he 
has  seen  fillings  made  by  some  of  these  gentlemen,  which 
for  beauty  and  solidity  he  does  not  think  can  be  surpassed, 
with  foil.  He  has  also  made  some  with  it  himself,  which  he 
believes  it  would  be  impossible  to  make  with  ordinary  gold 
foil.  The  crystals  possess  the  property,  when  pressed  firmly 
against  each  other,  of  welding  and  becoming  as  solid  and  al- 
most as  incapable  of  disintegration  or  crumbling  as  a  x)iece 
of  bullion  or  coin.  This  property  enables  a  skillful  manipu- 
lator to  supply  almost  any  loss  which  a  tooth  may  have  sus- 
tained, even  to  the  building  on  of  an  entire  crown.  Still  it 
will  never  supersede  the  use  of  gold  foil,  as  there  are  many 
cases  in  which  the  latter  can  be  used  more  advantageously 

*  Adhesive  gold  foil  has  been  known  to  some  dentists  for  many  years,  but  Dr.  R. 
Arthur  was  the  first  to  describe  the  proper  manner  of  using  it,  (A  Treatise  on  the 
Use  of  Adhesive  Gold  Foil,  p.  86,  1857,)  and  to  show  that  the  same  point  of  excel- 
lence could  be  ^ttainecl  with  it  as  with  the  best  preparations  of  crystalline  gold. 


MATERIALS  EMPLOYED   FOR   FILLING  TEETH.  293 

and  witli  more  facility  than  the  former.  Nor  will  the  em- 
ployment of  it,  in  the  opinion  of  the  author,  ever  become 
universal,  for  the  reason  that  more  care  and  skill  are  re- 
quired to  make  a  good  filling  with  it,  especially  when  the 
cavity  in  the  tooth  is  difficult  of  access,  than  with  leaf-gold. 

Tin  Foil. — This,  when  chemically  pure,  and  properly 
prepared,  is  less  objectionable,  than  most  of  the  articles 
hereafter  enumerated,  for  filling  teeth.  Under  favorable 
circumstances^  if  skillfully  introduced  it  will  prevent  the 
recurrence  of  caries.  But  if  the  fluids  of  the  mouth  are 
vitiated,  it  soon  oxydizes  and  turns  black,  and  then,  instead 
of  preventing,  it  rather  promotes  a  recurrence  of  the  dis- 
ease. This,  with  the  author,  has  constituted  an  insupera- 
ble objection  to  its  use.  As  an  excuse  for  its  employment, 
however,  many  operators  say,  that  in  consequence  of  its 
greater  malleability  than  gold,  it  can  oftentimes  be  em- 
ployd  for  filling  a  badly-shaped  and  large  cavity  when  the 
last  named  article  cannot  be  used.  We  do  not,  however, 
regard  this  as  a  valid  objection.  Any  tooth  that  can  be 
filled  with  tin,  can  be  equally  well  filled  with  gold.  Others 
again  employ  it,  because  manj'-  of  their  patients  are  not  able 
to  pay  for  a  more  costly  material.  Now,  if  a  tooth  is  worth 
filling  at  all,  it  is  worth  filling  in  a  proper  manner,  and 
with  a  suitable  material,  and  it  would  be  more  creditable 
to  the  operator  to  divide  the  expense  with  his  poor  patient, 
than  to  use  an  article  that  may  never  benefit  him. 

Lead  is  even  more  objectionable  than  tin,  as  it  is  more 
easily  decomposed  by  the  secretions  of  the  mouth,  and  by 
being  introduced  into  the  stomach,  might  be  productive  of 
serious  injury  to  the  general  health  of  the  patient.  But, 
happily,  this  article  is  now  seldom  used,  except  by  the  most 
ignorant  and  lowest  class  of  empirics. 

Gum  Mastic,  although  at  one  time  much  used,  is  now  sel- 
dom employed,  except  as  a  temporary  filling  when  the  pulp 


294  MATEKIALS   EMPLOYED   FOR   FILLING   TEETH. 

of  the  tooth  is  exposed,  and  when  used  even  for  this  pur- 
pose it  requires  to  be  often  renewed,  as  it  is  soon  dissolved 
by  the  saliva. 

Silver. — This  article  is  more  easily  oxydized  by  the  sep- 
tic (nitrous)  acid  of  the  mouth  than  tin,  and,  in  consequence 
of  its  greater  destructibility,  is  more  objectionable  than  the 
last  named  metal.  Besides,  it  is  harder  and  more  difficult 
to  consolidate. 

The  alloy  of  Bismuth,  Tin,  and  Lead,  or  D'Arcet's  Metal, 
as  it  is  sometimes  called,  is  used  in  a  state  of  fusion.  It  was 
never,  however,  very  popular,  as  the  temperature  required, 
to  fuse  it  being  that  of  boiling  water,  was  apt  to  excite  in- 
flammation in  the  tooth  and  its  membranes.  It  was  also 
found,  that  upon  cooling,  it  shrunk,  and  admitted  the  fluids 
of  the  mouth  between  it  and  the  walls  of  the  cavity  of  the 
tooth.     Its  use,  therefore^  has  been  discontinued. 

Amalgam,  better  known  by  the  name  of  mineral  cement, 
or  lithodeon,  is  the  most  pernicious  material  that  has  ever 
been  employed  for  filling  teeth.  It  almost  always  oxydizes 
in  the  mouth,  turning  the  teeth  black,  and  often  hastens 
their  destruction.  When  used  in  considerable  quantity,  it 
is  apt  to  exert  a  deleterious  effect  upon  the  alveolo-dental 
membranes,  gums,  and  other  parts  of  the  mouth. 

In  the  first  edition  of  this  part  of  his  work^  the  author 
expressed  his  disaj)probation  of  the  employment  of  this  arti- 
cle, and  since  that  time  he  has  had  abundant  opportunity  of 
observing  its  efi'ects,  and  he  is  fully  confirmed  in  the  unfa- 
vorable opinion  which  he  then  expressed  with  regard  to  it. 
Several  decided  cases  of  salivation_,  occasioned  by  the  use  of 
it_,  have  fallen  under  his  observation. 

Some  liave  endeavored  to  obviate  the  objections  existing 
to  its  use,  by  employing  silver  perfectly  pure  ;  but  it  mat- 
ters not  how  pure  this  metal  may  be,  the  amalgam  is  equally 
deleterious  in  its  effects.  Nor  would  it  be  any  better  if  pure 


INSTRUIktENTS   FOR   FORMING   THE   CAVITY. 


295 


gold  were  substituted  for  silver, 
does  the  mischief. 


It  is  the  mercury  that 


Platina  Foil,  from  its  capability  of  resisting  the  action  of 
the  acids  of  the  mouth,  would,  if  it  were  sufficiently  mal- 
leable, be  unobjectionable,  but  when  in  a  pure  state,  it  is 
too  hard  to  admit  of  thorough  consolidation  in  the  cavity  of 
a  tooth.  A  perfect  filling,  therefore,  cannot,  without  great 
difficulty,  be  made  with  it.  For  this  reason,  it  is  seldom 
used . 

INSTRUMRNTS  FOR  FORMING  THE  CAVITY. 

For  the  removal  of  the  diseased  part  of  a  tooth,  and  the 
formation  of  a  cavity  for  the  proper  reception  and  retention 
of  a  filling,  a  variety  of  instruments  are  required,  which 
should  be  constructed  from  the  best  steel,  and  so  tempered 
as  to  prevent  them  from  either  breaking  or  bending.  Their 
points  should  be  so  shaped,  that  they  may  be  conveniently 
applied  to  any  part  of  a  tooth,  and  made  to  act  readily  upon 
the  portion  which  it  may  be  necessary  to  remove. 

The   instruments  ^^°'  '^^• 

employed  for  this 
purpose  are  called 
excavators.  They 
may  be  formed  either 
with,  or  fitted  to_, 
separate  handles,  or 
be  made  to  fit  into 
one  common  han- 
dle, provided  with  a 
socket  for  the  pur- 
pose. Those  liav- 
ing  separate  handles 
are  more  convenient 
than  the  others,  but 
it  would  be  well  for  every  practitioner  to  be  provided  with 
a  number  of  both  kinds. 


296  INSTRUMENTS  FOR  FORMING  THE  CAVITT. 

The  flat  and  burr-headed  drills  are  very  useful  for  enlarg- 
ing the  orifice  of  a  cavity.  When  these  are  formed^  each  with 
a  handle,  the  pressure  of  the  instrument  against  the  hand, 
between  the  thumb  and  fore-finger^  is  often  productive  of 
much  irritation.  To  prevent  which,  a  socket  ring  or  shield 
like  the  one  represented  in  Fig.  75  or  76,  may  be  used  with 
great  advantage.*  It  consists  of  a  ring  adapted  to  the  fore 
or  middle  finger,  with  a  small  socket  attached  to  the  inside, 
as  shown  in  Fig.  75. 

Fi^^-  The  author  uses  an  open  ring  like  the  one 

represented  in  Fig  76,  with  an  arm  of  a  lit- 
tle more  than  an  inch  in  length,  attached, 
having  a  socket  at  the  extremity  resting  in 
the  hollow  of  the  hand,  between  the  thumb 
and  fore-finger.  This  he  finds  much  more 
convenient,  as  it  enables  him  to  apply  more 
pressure  upon  the  instrument  without  irri- 
tating the  finger,  and  as  the  ring  is  open,  it 
adapts  itself  more  readily  to  it. 

A  socket-handle,  however,  will  be  found  very  useful,  and 
when  used,  should  have  a  spring  attached  to  it  for  the 
more  perfect  retention  of  the  instrument.  Some  handles 
have  only  a  simple  socket  for  the  reception  of  a  burr-drill, 
but  the  one  with  a  spring  is  preferable.  This  may  not  only 
be  used  for  holding  drills,  but  it  also  answers  for  every  de- 
scription of  excavator.  The  drill  is  also  used  in  a  stock, 
turned  with  a  string  and  bow.  This  method  of  using  it  is 
objected  to  by  some  because  it  is  supposed  it  is  productive 
of  more  irritation  to  the  tooth  than  when  the  drill  is  moved 
simply  with  the  thumb  and  fore-finger. 

The  instrument  represented  in  Fig.  77,  is  a  modification 
of  a  very  ingeniously  contrived  drill-stock  invented  by  Dr. 
Maynard,  for  opening  a  cavity  in  the  grinding,  buccal  or 
posterior  approximal  surface  of  a  molar  tooth.     It  is  so  con- 

*  The  instrument  as  represented  in  cut  75,  was  invented  by  Dr.  A.  Westcott. 


INSTRUMENTS  FOR  FORMING  THE  CAVITY. 


297 


structed  as  to  move  a  drill,  pointing  in  three  different  direc- 
tions, but,  as  in  the  case  of  the  drill-stock  used  with  a  bow, 
the  original  instrument  requires  both  hands  to  work  it.     To 

Fia.  77. 


obviate  which  difficulty,  it  has  been  so  improved  that  it 
may  be  used  with  one  hand,  as  may  be  seen  by  the  above 
engraving. 


Fia.  78. 


Two  drill-stocks  were  presented  to  the  author  some  years 
ago,  the  first  by  Dr.  James  Eobinson,  of  London,  invent- 
ed by  Mr.  McDowell,  of  Lincoln  Inn  Fields.  This  instru- 
ment, is  represented  in  Fig.  78.  It  is  upon  the  principle 
of  the  helix  lever.  A  drill-stock  is  inserted  at  the  end  of 
the  screw,  moved  by  means  of  a  fem^e  screw  attached  to 

FiQ.  79. 


the  handle  of  the  instrument.     As  may  be  seen   from  the 
engraving,    drills,    pointing   in  three   directions,    may   be 
worked  in  it.     The  other  is  from  Mr.  John  Lewis,  formerly 
of  Burlington,  Vt.     This  is  represented  in  Fig.  79. 
20 


298  INSTRUMENTS  FOR   FORJUNa  THE   CAVITY, 

It  is  a  beautiful  and  admirably  contrived  instrument.  The 
drill  may  be  moved  in  it,  in  any  direction  from  a  line  with 
the  handle  to  a  parallel  with  the  same. 

For  opening  a  cavity  in  the  grinding  surface  of  a  tooth, 
partially  covered  by  projecting  portions  of  the  enamel,  the 
rose  or  burr-headed  di'ill  is  invaluable,  and  it  can  very  often 
be  advantageously  applied  to  the  side  of  a  tooth.  There  are 
many  cases,  too,  where  the  flat  triangular  pointed  drill  can 
be  conveniently  employed,  as  for  example,  when  it  becomes 
necessary,  as  it  often  does,  to  extend  the  cavity  further  into 
the  tooth  than  the  disease  has  penetrated.  A  three-sided 
instrument  brought  to  a  point,  as  also  a  cbisel-edged,  and 
a  four-sided  one  with  a  cutting  edge,  may  often  be  used  ad- 
vantageously in  cutting  away  portions  of  enamel  to  enlarge 

Fig.  80. 


Fig  81.  Fig.  82. 


the  orifice.     These  instruments  are  represented  in  Figs.  80, 
81  and  82.     But  the  cavity  can  seldom  be  completed  with 
either  the  flat  or  burr-headed  drill,  or  either  of  the  instru- 
Fio.  83.  ments  represented  above.     After  it  has 

been  opened,  and  the  orifice  made  suffi- 
ciently large,  it  should  be  finished  with 
flat  or  curve  pointed  excavators,  prop- 
erly adapted  to  the  purpose,  and  with 
instruments  of  this  sort,  it  should,,  in 
^  fact,  in  the  majority  of  cases,  be  wholly 

formed. 
"^         When,  however,  the  drill  is  used,  it 
should  be  frequently  dipped  in  water  to 
prevent  it  from  becoming  heated  by  the  friction  which  it 
produces.     This  precaution  ought  never  to  be  neglected. 

Fio.  83.  a,  6,  c,  d,  e,f,  g,  excavators  for  the  removal  of  caries  in  different  locali- 
ties in  teeth. 


MANNER   OF   FORMING  THE  CAVITY.  '       299 

Excavators,  shaped  like  those  represented  in  Fig.  83, 
have  heen  found  by  the  author  as  well  adapted  for  the  re- 
moval of  carious  portions  of  teeth  as  any  which  he  has  ever 
employed.  But  every  dentist  should  have  several  like  each 
of  these,  and  each  varying  in  size  from  the  other. 

As  the  proper  formation  of  the  cavity  greatly  depends  on 
having  suitable  instruments,  every  operator  should  be  provid- 
ed with  a  large  supply  of  burr-drills  and  excavators,  so  that 
he  may  never  be  at  a  loss  for  such  as  may  be  required  by  the 
peculiarity  of  any  case  which  may  present  itself.  He  ought, 
also,  to  be  supplied  with  the  means,  and  in  case  of  emer- 
gency, be  able  to  make  them  himself.  It  is  important,  too, 
that  these  instruments  be  always  sharp,  and  as  they  soon 
become  dull,  he  should  have  a  good  oil-stone  at  hand, 
upon  which  he  may,  at  any  moment,  sharpen  them. 
The  Arkansas  oil-stone,  on  account  of  its  great  durability, 
and  fineness  and  sharpness  of  grit,  is,  on  some  accounts, 
preferable  to  any  other. 

MANNER  OP   FORMING  THE   CAVITY. 

The  formation  of  the  cavity  in  a  tooth  for  the  reception 
of  a  filling,  is  very  often  an  important  part  of  the  operation, 
and  though  usually  the  easiest,  is  sometimes  attended  with 
much  difficulty.  The  removal  of  the  diseased  part  is  not 
always  all  it  is  necessary  to  do,  preparatory  to  the  in- 
troduction of  the  gold.  The  cavity  must  be  so  shaped,  as 
when  properly  filled,  to  prevent  the  liability  of  the  filling 
from  coming  out.  The  part  of  the  tooth,  too,  surrounding 
the  orifice,  should  present  no  rough  or  brittle  edges  or 
points.  The  bottom  of  the  cavity  should  be  as  nearly  the 
size  of  the  orifice  as  it  is  possible  to  make  it,  and  it  would 
be  better  to  have  it  even  a  little  larger  than  any  smaller. 
But  the  difierence  between  the  size  of  the  one  and  the  other 
should  never  be  very  great.  If  the  interior  of  the  cavity  is 
much  larger  than  the  orifice,  it  will  be  difficult  to  make  the 
filling  sufficiently  firm  and  solid  to  render  it  absolutely  im- 


300  MANNER   OF   FORMINa  THE   CAVITY. 

permeable  to  the  fluids  of  tlie  moutli ;  and  if,  on  the  other 
hand,  the  orifice  is  larger  than  the  bottom  of  the  cavity,  it 
will  be  difficult  to  obtain  sufficient  stability  for  the  filling, 
to  prevent  it  from  ultimately  loosening  and  coming  out. 
It  often  happens,  however,  that  the  situation  and  extent  of 
the  decay  is  such,  as  to  render  it  impossible  to  make  the 
cavity  as  large  at  the  bottom  as  at  the  orifice,  and  when 
this  is  the  case,  several  pits  or  circular  grooves  should  be 
cut  in  the  inner  walls,  for  the  purpose  of  obtaining  as  much 
security  for  the  filling  as  possible.  By  properly  attending 
to  this  precaution,  a  filling  may  be  so  inserted  as  to  prevent 
it  from  coming  out. 

As  a  general  rule  it  is  easier  to  form  a  cavity  in  the 
grinding  surface  of  a  molar  or  bicuspid,  than  in  any  other 
tooth  or  part  of  a  tooth,  though  it  sometimes  happens,  that 
even  here,  it  is  attended  with  difficulty,  and  especially 
when  the  decay,  commencing  in  the  centre,  follows  the  sev- 
eral depressions  which  run  out  from  it.  In  cases  of  this 
sort,  the  edges  bordering  on  and  covering  the  afiected  parts, 
which  are  often  thick  and  very  hard,  should  be  cut  away, 
together  with  the  subjacent  decayed  dentine,  and  these 
radiating  excavations  should  open  fully  into  the  central 
cavity,  and  made  sufficiently  wide  and  deep  to  admit  of 
being  filled  to  their  extremities  in  the  most  perfect  and  sub- 
stantial manner.  The  surface  of  a  filling  occupying  a 
cavity  of  this  kind  presents  a  sort  of  stellated  appearance. 
When  two  or  more  decayed  places,  separated  only  by  very 
thin  walls  of  tooth  substance,  these  should  be  cut  away  and 
a  cavity  formed  large  enough  to  include  all  the  diseased 
points,  as  one  large  filling  will  secure  the  preservation  of 
the  tooth  more  eftectually  than  by  filling  each  cavity  sep- 
arately. 

Before  a  cavity  can  be  prepared  in  the  approximal  surface 
of  a  tooth,  it  is  usually  necessary  to  sei^arate  the  organ  to 
be  operated  on  from  the  adjoining  one.  This  may  be  done 
either  with  a  file,  or  by  pressure,  operating  between  the 
teeth  in  opposite  directions.     Each  of  these  methods  has  its 


MANNER   OF   FORMING  THE  CAVITT.  301 

preference.  When  caries  has  extended  over  nearly  the 
whole  of  the  approximal  surface,  so  that  after  the  removal 
of  the  diseased  part,  the  orifice  of  the  cavity  will  be  sur- 
rounded by  a  thin,  brittle  and  irregular  wall,  and  in  indi- 
viduals in  whom  there  is  a  decided  scorbutic  tendency,  or 
who  have  suffered  from  the  use  of  mercurial  medicines  or 
syphilitic  disease,  and  in  aged  persons,  the  former  is  the 
preferable  method.  But  when  the  caries  has  spread  over 
only  a  small  portion  of  the  surface  of  the  tooth,  and  is  sur- 
rounded by  sound,  healthy  enamel,  the  latter  method,  in 
individuals  in  whom  there  is  no  manifest  tendency  to  in- 
flammation or  sponginess  of  the  gums,  and  especially  in 
young  subjects,  should  be  adopted.  The  manner  of  sepa- 
rating teeth  with  a  file,  has  been  already  described;  it  will 
only  be  necessary,  therefore,  in  this  place,  to  offer  a  few 
remarks  on  separating  by  pressure.* 

The  following  are  the  advantages  of  the  latter  over  the 
former  method,  where  it  can  be  resorted  to  with  safety; 
namely,  after  the  removal  of  the  pressure,  the  teeth  almost 
immediately  come  together,  leaving  no  aperture  to  injure 
their  beauty ;  and  what  is  of  still  greater  importance,  the 
dentine  around  the  external  surface  of  the  filling  is  not  ex- 
posed to  the  action  of  the  secretions  of  the  mouth,  or  other 
agents  capable  of  exerting  upon  it  a  deleterious  effect.  On 
the  other  hand,  some  are  of  opinion,  that  by  the  approxima- 
tion of  the  teeth,  a  lodgment  is  afforded  to  corrosive  agents, 
upon  the  presence  of  which  the  disease  was,  in  the  first 
instance,  produced,  and  which  would,  of  necessity,  soon 
cause  a  recurrence  of  it.  In  replying  to  this  objection,  it 
is  only  necessary  to  observe,  that  the  parts  of  teeth  first 
attacked  by  caries,  were  the  points  in  contact  with  each 
other,  where  the  enamel  may  be  supposed  to  have  sustained 
some  injury  by  pressure  and  friction,  thus  rendering  them 
more  vulnerable  at  these  points  to  the  action  of  the  causes 
that  produced  the  disease.     By  properly  replacing  tlie  dis- 

*  This  method  of  separating  teeth  was  first  adopted  by  Dr.  Eleazar  Parmlj,  of 
New  York. 


302  MAXXER   OF   FORMXG   THE  CAVITT. 

eased  parts  with  gold,  the  external  surfaces  of  the  fillings 
will  be  the  only  parts  that  come  in  contact  with  each  other 
in  such  a  way  as  to  render  them  liable  to  injury  from  the 
above  mentioned  mechanical  causes ; .  and  the  enamel  around 
them,  if  proper  attention  to  cleanliness  be  observed,  is  not 
so  liable  to  be  acted  on  by  chemical  agents  as  the  dentinal 
parts  of  the  organs. 

But  teeth  cannot  always  be  separated  by  pressure  with 
impunity ;  it  can  only  be  done  with  safety  in  certain  cases. 
As  a  general  rule,  the  writer  is  of  the  opinion  that  it  ought 
not  to  be  attemj)ted  after  the  thirtieth  or  fortieth  year  of 
age,  though  it  doubtless  may  sometimes  be  done  with  safety 
at  a  later  period.  The  diseased  action,  excited  for  the  time, 
in  the  sockets  of  the  teeth,  does  not  so  readily  subside,  at  a 
later  age,  and  it  has  in  some  instances,  been  known  to  result 
in  the  loosening  and  ultimate  loss  of  the  organs.  In  one 
case  which  came  under  the  observation  of  the  author,  the 
inflammation  extended  to  the  lining  membrane  and  pulp, 
causing  their  disorganization,  and  as  a  consequence,  the 
death  of  the  tooth. 

The  pressure  ought  never  be  too  actively  exerted;  it 
should  be  gradual  and  constant.  From  four  to  twelve  days 
are  usually  required  for  the  separation  of  two  teetli  suffi- 
ciently for  the  removal  of  the  decayed  part  and  the  intro- 
duction of  a  filling.  After  they  have  been  separated  in  this 
way,  they  should  be  kept  apart,  without  any  increase  of 
pressure,  until  the  soreness  in  the  sockets  shall  have  sub- 
sided, before  any  farther  steps  are  taken  in  the  operation. 
Only  two  teeth  should  be  separated  in  the  front  part  of  the 
mouth,  in  the  same  jaw,  at  the  same  time. 

The  pressure  is  usually  made  by  the  introduction  of  a  thin 
wedge  of  soft  wood,  a  piece  of  gum  elastic,  tape,  or  a  little 
raw  cotton,  between  the  crowns  of  two  teeth,  rei:)lacing  it 
every  day  or  two  with  a  thicker  piece.  The  writer  prefers 
gum  elastic  to  any  other  substance  he  has  employed  for  the 
purpose.  But  the  object  may  be  readily  attained  with  other 
substances. 


INSTRUMENTS  FOR   INTRODUCING   GOLD   FOIL.  303 

But  "wlietlier  the  teetli  be  separated  with  a  file  or  by 
pressure,  the  aperture  shouki  be  sufficiently  wide  to  enable 
the  dentist  to  operate  with  ease;  otherwise,  it  will  be  im- 
possible to  remove  the  caries  and  fill  the  teeth  in  a  proper 
manner. 

After  every  particle  of  decomposed  dentine  has  been 
removed,  the  cavity  should  be  thoroughly  cleansed  before 
the  filling  is  introduced.  This  may  be  done  by  first  inject- 
ing tepid  water  into  it  with  a  properly  constructed  syringe, 
and  afterwards  wiping  it  dry  with  a  small  lock  of  raw  cot- 
ton fixed  upon  the  point  of  a  probe  or  excavator ;  or,  the 
cavity  may,  in  the  first  place,  be  wiped  with  a  little  raw 
cotton,  moistened  with  water,  and  afterwards  with  dry 
cotton.  Some  recommend  tissue  paper  for  drying  the  cav- 
ity, for  the  reason  that  it  absorbs  moisture  more  readily 
than  cotton.  The  latter,  however,  is  the  most  convenient, 
and  is  equally  as  good  as  the  former.  Its  absorbing  (|uali- 
ties  may  be  increased  by  boiling  it  for  fifteen  or  twenty 
minutes  in  a  tolerably  strong  alkaline  solution.  When  this 
is  done,  it  should  be  thoroughly  washed  and  dried  before 
using.  It  is  desirable  that  the  cavity  should  be  perfectly 
dry  before  the  filling  is  introduced. 

IN  STRUM  RNTS  FOR  INTRODUCING  GOLD  FOIL. 

For  introducing  and  consolidating  the  gold,  a  number  of 
instruments  are  required,  which  should  be  sufficiently  strong 
to  resist  any  amount  of  pressure  the  dentist  may  be  capa- 
ble of  exerting  in  the  operation.  They  should  have  round 
or  octangular  handles,  large  enough  to  prevent  the  liability 
of  being  broken,  and  to  enable  him  to  grasp  them  firmly  in 
his  hand.  Their  points  should  vary  in  size,  though  none 
should  be  very  large.  Several  should  be  straight,  but  for 
the  most  part,  they  require  to  be  curved — some  very  slight- 
ly, others  to  form  with  the  shaft  of  the  instrument  an  an- 
gle of  ninety  degrees.  Most  of  them  should  have  a  slim 
wedge-shape.      Some,  however,  both  of  the  straight  and 


304  INSTRUMENTS   FOR  INTRODUCING  GOLD   FOIL. 

curved  instruments,  should  have  blunt  serrated  points,  and 
a  few  should  have  highly  polished  oval  points,  for  finish- 
ing the  surfaces  of  fillings  in  the  grinding  and  other  ex- 
posed surfaces  of  teeth.  Formerly  most  dentists  employed 
for  introducing  and  consolidating  the  gold,  simple  blunt- 
pointed  pluggers  ;  but,  it  is  impossible  with  such  instru- 
ments to  make  a  filling  as  firm  and  solid  as  it  should  be  for 
the  perfect  preservation  of  a  tooth,  and  especially  if  the 
cavity  is  large.  From  one-fourth  to  one-half  more  gold 
can  be  introduced  into  a  tolerably  large  cavity,  with  a 
wedge-pointed  than  with  a  blunt-pointed  instrument. 

The  sides  of  the  wedge-pointed  pluggers  should  be  left  a 
little  rough,  for  the  purpose  of  preventing  them  from  cut- 
ting the  gold,  and  there  should  be  two  or  three  small  notches 
filed  across  their  edges.  When  thus  prepared,  the  gold 
can  be  more  perfectly  controlled  and  more  readily  conveyed 
to  the  bottom  of  the  cavity  tlian  with  smoother  edged  in- 
struments. The  blunt  pointed  instrument,  or  those  used 
for  condensing  the  extruding  extremities  of  the  folds  of 
gold,  should,  as  before  stated,  have  serrated  points,  that  the 
surface  of  the  metal  may  be  thoroughly  integrated  in  the 
process  of  consolidation. 

This  general  description  will  serve  to  convey  a  tolerably 
correct  idea  of  the  description  of  instruments  required  for 
the  operation  ;  but^  no  two  dentists  have  their  filling  in- 
struments precisely  alike ;  each  has  them  constructed  in 
such  a  way  as  he  thinks  will  enable  him  to  apply  them  most 
easily  and  efficiently  to  the  various  parts  of  a  tooth  which 
may  require  filling.  In  the  chapter  on  filling  individual 
cavities  in  teeth,  cuts  of  most  of  the  instruments  employed 
in  the  operation  will  be  found. 

Instruments  with  points  somewhat  differently  construct- 
ed, are  required  for  filling  teeth  with  crystalline  or  sponge 
gold. 


INTRODUCING  AND   CONSOLIDATING   GOLD   FOIL.  305 


MANNER   OP   INTRODUCING  AND   CONSOLIDATING   GOLD  FOIL  AND 
FINISHING  THE  SURFACE  OF  THE  FILLING. 

The  operator,  being  provided  with  the  necessary  instru- 
ments, should  cut  his  gold  with  a  pair  of  scissors,  into  strips 
of  from  half  an  inch  to  an  inch  wide.  Each  of  these  should 
be  loosely  rolled  or  folded  together  lengthwise,  and  after 
the  cavity  has  been  properly  cleansed  and  dried,  the  end  of 
one  should  be  introduced  and  carried  to  the  bottom  of  the 
cavity,  with  a  straight  or  curved  wedge-pointed  instru- 
ment ;  the  roll  on  the  outside  should  then  be  folded  on  the 
part  first  inserted.  The  folding  should  be  commenced  on 
one  side  of  the  cavity,  and  the  inner  end  of  each  fold  taken 
to  the  bottom,  the  outer  extending  nearly  a  twelfth  or 
an  eighth  of  an  inch  on  the  outside  of  the  orifice,  and 
thus,  fold  after  fold  is  introduced,  until  no  more  can, 
in  this  manner,  be  forced  into  the  cavity.  Having 
proceeded  thus  far  with  the  operation,  the  instrument 
should  be  forced  through  the  centre  of  the  filling,  and  the 
gold  firmly  pressed  against  the  walls  of  the  cavity.  The 
opening  thus  made  should  be  filled  in  the  manner  as  first 
described ,  and  this  time  it  should  be  packed  in  as  tightly  as 
possible.  This  done,  the  operator  should  endeavor  to  force 
in  a  small  wedge-pointed  instrument,  at  the  side  or  some 
other  part  of  the  cavity  ;  and  thus  he  may  proceed  until 
he  has  tried  every  part  of  the  plug  ;  filling,  as  he  proceeds, 
every  opening  which  he  makes,  and  exerting,  in  the  pack- 
ing of  the  gold,  all  the  pressure  which  he  can  put  on,  with- 
out endangering  the  tooth.  If  one  roll  or  fold  of  gold  is 
not  enough,  he  may  take  another  and  another,  until  the 
cavity  is  thoroughly  filled. 

The  advantage  to  be  derived  from  introducing  the  gold  in 
this  manner  is  obvious.  By  extending  the  folds  from  the 
orifice  to  the  bottom  of  the  cavity,  the  liability  of  the  gold 
to  crumble  and  come  out,  is  effectually  prevented,  and  by 
introducing  it  with  a  wedge-pointed  instrument,  it  may  be 


306  INTRODUCING   AND   CONSOLIDATING   GOLD   FOIL. 

pressed  out  into  all  tlie  depressions  of  the  walls  of  the  cavi- 
ty, and  rendered  altogether  more  solid  than  it  could  other- 
wise be  made.  The  adhesiveness  of  the  gold  may  be  in- 
creased by  slightly  annealing  in  the  flame  of  a  spirit  lamp, 
after  it  has  been  made  into  rolls  or  folds. 

After  the  cavity  has  been  completely  filled,  every  por- 
tion of  the  projecting  part  of  the  gold  is  thoroughly  con- 
solidated, either  with  a  straight  or  curved  small  blunt- 
pointed  instrument,  as  may  be  most  convenient ;  or  if  the 
filling  is  in  the  side  of  a  tooth  facing  another,  it  may  be 
compressed  with  the  angle  of  the  point  of  the  plugger,  mak- 
ing the  adjoining  organ  a  kind  of  fulcrum  for  the  instru- 
ment. After  the  filling  has  been  thus  consolidated^  as  long 
as  it  can  be  made  to  yield  in  the  least  to  the  pressure  of  the 
instrument,  the  protruding  parts  may  be  scraped  or  cut, 
if  in  the  grinding  face,  and  filed,  if  in  the  side,  down  to 
the  tooth,  so  as  to  form  a  smooth,  uniform,  gently  swelling 
or  perfectly  flat  surface.  If  in  this  part  of  the  operation 
any  portion  of  the  gold  should  crumble  or  be  dislodged, 
which  it  will  not  do  if  it  has  been  properly  introduced  and 
consolidated,  the  injury  may  be  repaired  by  making  in  the 
part  of  the  plug,  where  it  has  occurred,  an  opening,  and 
filling  it,  or  by  the  removal  of  the  whole  of  the  filling  and 
the  introduction  of  another.  Every  part  of  the  surface  of 
the  filling  should  be  uniform  and  free  from  the  slightest 
indentations  which  may  aflbrd  a  lodgment  to  clammy  mucus 
or  extraneous  matter  of  any  sort.  This  is  a  point  which 
should  never  be  lost  sight  of,  for,  however  excellent  the  fill- 
ing may  be  in  other  resj^ects,  if  the  surface  is  not  smooth, 
uniform,  and  flush  with  the  orifice  of  the  cavity _,  the  object 
intended  to  be  accomplished  by  it  will  be  partially  if  not 
wholly  defeated.  If  any  portions  of  the  gold  have  been 
forced  over  the  edge  of  the  orifice  of  the  cavity,  they  should 
be  carefully  removed,  either  with  a  file  or  sharp-pointed 
cutting  instrument  suited  to  the  purpose.  This  precaution 
should  never  be  neglected^  especially  when  the  filling  is  in 
the  approximal  surface  of  a  tooth  where  a  portion  of  the 


INTRODUCING  AND   CONSOLIDATING   GOLD   FOIL.  307 

gold  is  very  liable  to  be  forced  up  or  down  upon  the  neck, 
as  the  tooth  may  happen  to  be  in  the  upper  or  lower  jaw. 

After  having  prepared  the  surface  of  the  filling  in  the 
manner  as  here  described,,  it  may  be  rubbed  with  finely  pow- 
dered pumice  stone,  or,  with  what  is  by  far  better,  a  small 
jiiece  of  Arkansas  oil-stone,  until  all  the  file  scratches  or 
other  asperities  are  removed.  If  the  filling  is  in  the  grind- 
ing, buccal  or  palatine  surface  of  a  molar  or  bicuspid,  a  long 
piece  of  the  stone,  having  a  small  triangular  and  slightly 
oval  point,  may  be  used,  or,,  if  powdered  pumice  stone  be 
employed,  it  may  be  used  on  the  point  of  a  similarly  shaped 
piece  of  soft  wood,  previously  moistened  in  water.  For  a 
filling  in  the  approximal  surface  of  a  tooth,  the  oil-stone 
may  be  shaped  like  the  pinion  file  of  a  clock,  and  in  either 
case  it  should  be  frequently  dipped  in  water,  and  when  its 
pores  become  filled  with  gold,  the  surface  may  be  ground 
ofi"  by  rubbing  it  on  a  corundum  slab  ;  or  if  pumice  is  used, 
it  may  be  applied  with  floss  silk,  moistened  with  water,  by 
drawing  it  backwards  and  forwards  across  the  surface  of  the 
filling. 

After  all  the  asperities  have  been  removed,  the  surface 
should  be  washed  until  every  particle  of  grit  is  removed. 
This  done  it  maybe  polished  with  a  suitable  burnisher,  dip- 
ping it  in  water  from  time  to  time,  having  a  small  quantity 
of  pure  castile  soap  dissolved  in  it,  until  the  filling  is  ren- 
dered as  brilliant  as  a  mirror.  Having  proceeded  thus  far, 
it  may  be  again  washed,  and  the  operation  completed  by 
rubbing  it  from  three  to  six  minutes  with  dry  floss  silk. 

When  the  caries  has  penetrated  nearly  to  the  pulp  cavi- 
ty, the  presence  of  a  gold  or  any  other  metallic  filling,  is 
sometimes  productive  of  considerable  pain  and  irritation, 
especially  when  hot  or  cold  fluids  are  taken  into  the  mouth, 
or  during  the  inspiration  of  cold  air.  In  some  cases,  in- 
flammation and  suppuration  of  the  lining  membrane  and 
pulp  supervenes.  To  prevent  these  disagreeable  efiects,  a 
variety  of  means  have  been  proposed.  Dr.  Solyman  Brown 
recommends  placing  asbestos,  this  being  a  non-conductor  of 


308         iNTRODUcma  and  consolidating  gold  foil. 

caloric,  on  the  bottom  of  the  cavity,  previously  to  the 
introduction  of  the  gold.  Others  recommend  placing  a 
thin  piece  of  cork,  and  others,  again,  oiled  silk,  between 
the  filling  and  the  bottom  of  the  cavity.  The  author  pre- 
fers a  thin  layer  of  gutta  2jerclia.  This  is  less  destructible 
than  either  of  the  two  last  named  articles,  and  can  be  more 
conveniently  and  more  perfectly  applied.  It  may  be  used 
in  the  form  of  a  thick  solution,  jDrepared  with  chloroform, 
or  a  layer  of  thin  gutta  percha  cloth  may  be  placed  at  once 
in  the  bottom  of  the  cavity.  When  the  solution  is  used,  a 
drop  may  be  placed  in  the  cavity,  and  a  sufficient  time  al- 
lowed for  the  chloroform  to  evaporate,  before  introducing 
the  filling.  A  thin  layer  of  ^'Hill's  stopping,"  of  which 
gutta  percha  forms  the  principal  ingredient,  may  be  used 
with  equal  advantage. 

The  time  required  to  fill  a  tooth  well,  by  an  expert  ope- 
rator, may  be  said  to  vary  from  thirty  minutes  to  two  hours 
and  a  half,  according  as  the  cavity  is  large  or  small,  or  fa- 
vorably or  unfavorably  situated,  and  in  some  cases  a  much 
longer  time  will  be  required.  The  author  has  found  it  ne- 
cessary in  filling  some  cavities,  especially  when  the  restora- 
tion of  a  large  portion  of  the  crown  was  called  for,  to  bestow 
as  many  as  six  hours  constant  labor  upon  the  operation. 
Much  less  time  and  skill  are  usually  required  to  fill  a  cavity 
in  the  grinding  than  in  the  approximal  surface  of  a  tooth, 
and  the  operation  in  either  place  to  be  beneficial  to  the  pa- 
tient, must  be  performed  in  the  most  thorough  manner,  and 
the  dentist  who  does  not  feel  the  importance  of  making  such 
an  operation,  should  never  be  entrusted  with  the  manage- 
ment of  the  disease  of  these  important  organs. 

In  every  part  of  the  operation,  the  dentist  should  so 
guard  his  instruments  as  to  prevent  them  from  slipping, 
and  he  will  usually  be  better  able  to  do  this  by  standing  a 
little  to  the  right  and  behind  his  patient  than  in  any  other 
position.  In  filling  the  lower  teeth  he  should  stand  several 
inches  higher  than  while  filling  the  upper,  and  to  enable 
him  to  do  this,  he  should  be  provided  with  a  stool,  to  be 


INTRODUCING   AND   CONSOLIDATING   GOLD   FOIL.  309 

used  whenever  lie  may  find  it  necessary  to  occupy  a  more 
elevated  position.  When  it  can  be  done,  lie  sliould  grasp 
the  tooth  with  the  thumb  and  fore-finger  of  his  left  hand, 
not  only  to  prevent  it  from  being  moved  by  the  pressure  he 
applies,  but  also  to  catch  the  point  of  the  instrument  in 
case  it  should  slip ;  but  if  he  is  always  careful  to  press  in  a 
direction  towards  the  orifice  of  the  cavity,  this  need  never 
happen,  but,  nevertheless,  he  should  always  use  the  neces- 
sary precaution  to  prevent  such  accident.  When  he  cannot 
shield  the  mouth  with  the  .thumb  and  finger  of  his  left 
hand,  he  should  let  the  thumb  or  one  of  the  fingers  of  his 
right  rest  either  upon  the  tooth  he  is  operating  on,  or  upon 
some  other. 

For  the  manner  of  filling  individual  cavities  in  teeth,  the 
reader  is  referred  to  the  next  chapter. 


CHAPTER     FOURTH. 

FILLING  INDIVIDUAL  CAVITIES  IN  TEETH. 

To  describe  the  method  of  filling  each  individual  cavity 
in  every  locality  in  which  a  tooth  is  liable  to  be  attacked  by 
caries,  would  be  both  tedious  and  difficult.  But^  as  this  is 
one  of  the  most  important,  and,  at  the  same  time^  one  of 
the  most  difficult  operations  in  dental  surgery,  it  may  be 
well  to  enter  a  little  more  into  detail  upon  the  subject,  than 
we  have  as  yet  done.  But  in  doing  this,  the  writer  will 
confine  himself,  for  the  most  part,  to  the  manner  of  filling  a 
cavity  in  each  of  the  following  localities,  which  are  the  parts 
of  teeth  most  liable  to  become  the  seat  of  caries. 

First. — In  the  approximal  and  labial  surfaces  of  the  supe- 
rior incisors  and  cuspidati,  and  palatine  surfaces  of  the  for- 
mer of  tlie  above  mentioned  classes  of  teeth — the  latter  being 
rarely  attacked  by  caries  on  their  posterior  surface. 

Second. — In  the  grinding,  approximal_,  buccal  and  pala- 
tine surfaces  of  the  molars  and  ])icuspids  of  the  upper  jaw. 

Third. — In  the  approximal  surfaces  of  the  inferior  incisors 
and  cuspidati. 

Fourth. — In  the  grinding,  approximal,  and  buccal  sur- 
faces of  the  molars  and  bicuspids  of  the  lower  jaw. 

Other  i)arts  of  the  teeth  sometimes  become  the  seat  of  ca- 
ries, but  the  foregoing  are  the  localities  most  liable  to  be  at- 
tacked by  the  disease. 

FILLING  THE  SUPERIOR  INCISORS  AND  CUSPIDATI. 

In  describing  the  manner  of  introducing  a  filling  in  one 
of  the  first  named  teeth,  we  shall  commence  with  the  right 


FILLING  SUPERIOR  INCISORS  AND   CUSPID  ATI.  311 

approximal  surface  of  the  left  central  incisor.  The  direc- 
tions we  propose  giving  for  the  performance  of  the  operation 
here,  will  he  applicahle  to  the  same  surface,  with  a  few  ex- 
ceptions, of  all  the  upper  incisors.  As  a  general  rule  the 
gold  should  be  introduced  from  behind  the  teeth  forwards 
and  upwards,,  and  for  the  following  reasons  :  1,  When  the 
aperture  between  the  teeth  has  been  formed  with  a  file,  it 
should,  when  the  circumstances  of  the  case  will  permit,  and 
for  reasons  stated  in  another  place,  be  made  wider  behind  than 
before,  consequently,  the  diseased  part  can  be  most  easily 
approached  from  this  direction.  2.  The  gold,  in  the  major- 
ity of  cases,  can  be  more  conveniently  introduced  from 
the  jDalatine  side^  and  the  force  required  for  condensing  it 
can  be  more  advantageously  applied. 

The  exceptions  to  the  above  rule,  are,  when  the  ajDproxi- 
mal  side  of  the  tooth  is  turned  slightly  forwards  towards  the 
lip,  and  when  the  caries  is  situated  nearer  the  labial  than 
the  palatine  angle;  also,  when  the  teeth,  instead  of  occu- 
pying a  vertical  position  in  the  alveolar  border,  or  project- 
ing slightly  as  they  usually  do,  incline  backwards  towards 
the  roof  of  the  mouth.  It  sometimes  happens,  too,  when 
they  are  separated  by  pressure,  that  the  diseased  part  can 
be  most  conveniently  reached  from  before. 

The  instrument  which  the  writer  has  found  best  adapted 
for  the  introduction  of  the  gold  in  a  cavity  in  the  right  ap- 
proximal surface  of  an  incisor  or  cuspid  tooth,  is  represented 
in  Fig.  84.  The  width  and  length,  as  well  as  the  curva- 
ture or  angle  of  the  point,  should  vary  according  to  the 
size  of  the  cavity  and  the  width  of  the  aperture  between 
the  teeth. 

■710.  84. 


The  stem  of  the  instrument  as  well  as  the  shank  sliould 
be  strong  enough  to  sustain  any  amount  of  pressure  which 
it  may  be  necessary   to  apply  in  forcing  the  folds  of  gold 


312 


FILLING  SUPEKIOR  INCISORS  AND   CUSPIDATI. 


tightly  against  each  other.     The  point  should  be  wedge- 
shai3ed_,  and  the  extremity  serrated. 

The  decayed  part  of  the  tooth  having  been  removed^  and 
the  cavity  properly  shaped,  cleansed  and  dried,  is  ready  for 
the  reception  of  the  gold. 

The  patient  may  be  seated  in  a  chair  sufficiently  high 
to  bring  his  head  on  a  level  with  the  breast  of  the  operator, 
and  recline  on  the  head-piece  of  the  chair  with  the  face  up- 
wards. The  patient  being  thus  seated,  the  operator  stand- 
ing upon  the  right  side,  should  support  his  head  firmly 
with  his  left  arm  during  the  operation,  while  with  the 
thumb  and  fore-finger  of  the  hand  of  the  same,  the  strip  or 
roll  of  gold  is  held,  and  one  end  placed  in  a  proper  position 
to  be  introduced  into  the  cavity  of  the  tooth.  The  middle 
finger  of  the  same  hand,  ought,  at  the  same  time,  to  rest  on 
the  end  of  a  tooth  to  the  left  of  the  one  on  which  the  opera- 
tion is  being  performed,  while  with  the  little  finger  the 
lower  lip  may  be  gently  depressed. 

During  the  introduction  of  the  gold,  the  instrument  (see 
Fig.  84)  should  be  held  in  the  right  hand  of  the  operator  in 
the  manner  as  represented  in  Fig.  85,  but  grasped  with 
sufficient  firmness  to  prevent  it  from  slipping  or  rotating. 

In  introducing  the 
the  first  fold 
should  be  applied  a- 
gainst  the  uj)per  wall 
of  the  cavity,  that  the 
pressure  may  always 
be  exerted  in  a  direc- 
tion towards  the  ex- 
tremity of  the  root^ 
applying  each  additional  fold  as  closely  to  the  preceding 
one  as  possible.  The  folds  should,  also,  in  their  introduc- 
tion, be  applied  as  closely  to  the  labial  and  palatine  walls 
of  the  cavity  as  possible,  but  always  directing  the  pressure, 
when  tliese  are  thin  and  brittle,  in  a  direction  towards  the 
axis  of  the  root. 


Fig.  85. 


gold 


FILLING  SUPERIOR  INCISORS  AND   CUSPID  ATI.  313 

When  the  lower  part  of  the  orifice  of  the  cavity  is  very 
narrow,  as  is  often  the  case,  especially  when  it  extends 
nearly  to  the  labial  angle  of  the  tooth,  it  is  often  necessary 
to  change  the  instrument  for  one  having  a  smaller  point. 

To  carry  a  fold  of  gold  upon  the  point  of  the  instrument, 
without  breaking  or  cutting  it,  to  the  bottom  of  a  cavity  in 
a  tooth,  requires  some  tact.  The  point  should  never  be 
carried  directly  towards  the  bottom  of  the  cavity.  On  en- 
tering the  orifice,  it  should  be  directed  towards  the  wall  of 
the  cavity  opposite  the  one  against  which  the  folds  are  first 
laid.  Equally  as  much  tact,  too,  is  required  to  prevent 
displacing  the  gold  before  a  sufficient  quantity  has  been 
introduced  to  procure  support  for  it  from  the  surrounding 
walls.  This  last  is  an  accident  particularly  liable  to  occur 
with  young  practitioners,  when  the  cavity  is  superficial  and 
has  a  large  orifice.  To  prevent  this,  the  folds  of  gold 
should  be  long  enough  to  project  a  considerable  distance 
from  the  orifice,  that  they  may  receive  some  support  from 
the  adjoining  tooth,  and  the  thumb  and  fore-finger  of  the 
left  hand  of  the  operator.  In  this  way  the  gold  may  be 
prevented  from  being  moved  or  displaced,  until  the  opera- 
tion has  arrived  at  that  stage  when  sufficient  support  and 
stability  shall  have  been  obtained  for  it  from  the  walls  of 
the  cavity. 

There  are  some  cases  in  which  an  instrument  like  the  one 
represented  in  Fig.  86,  can  be  very  advantageously  employed 
in  the  introduction  of  the  gold ;  but  yiq. 

in  the  majority  of  cases,  the  instru- 
ment represented  in  Fig.  84  will  be 
found  more  convenient  and  efficient  than  this . 

After  having  filled  the  cavity  so  thoroughly  that  a  small 
wedge-pointed  instrument  cannot  be  made  to  penetrate  the 
gold  at  any  point,  the  extruding  portion  of  the  filling 
should  be  consolidated,  beginning  with  the  overlapping 
portions  upon  the  lower  part  of  the  tooth  and  edge  of  the 
posterior  wall.  These  should  be  carefully  and  firmly  pressed 
in  the  direction  of  the  orifice  of  the  cavity,  with  an  iustru- 
21 


314  FILLTXG   SUPERIOR   INCISORS   AND    CUSPIDATI. 

ment  like  the  one  represented  below.    This  clone,  it  ma,y  be 
Pjg  gy  firmly  applied  to  every  part  of  the  sur- 

face of  the  filling,  repeating  the  pres- 
^    sure  as  long  as  the  point  of  the  instru- 
ment can  be  made  to  indent  the  gold. 
When  the  space  between  the  two  teeth  is  too  narrow  to 
admit  the  application  of  an  instrument  like  the  one  repre- 
sented in  Fig.  87,  one  having    a  differently  shaped  point 
may   be   used.      See   Fig.    88.      The   operator   should   be 
provided  with  two  or  three  instruments  like  each  of  the  two 
pjg  gg  last,  varying  both  in  the  size,  length 

and  curvature  of  their  points.  Some- 
5  times,  he  will  be  able  to  use  one  with 
more  efficiency  than  another. 
During  the  process  of  consolidating  the  gold,  the  tooth 
should  be  firmly  grasped  between  the  thumb  and  fore-finger 
of  the  left  hand  of  the  operator,  to  prevent  it  from  being 
pushed  too  forcibly  against  the  opposite  side  of  the  socket, 
while,  at  the  same  time,  the  end  of  the  fore-finger,  by 
being  placed  above  the  instrument,  assists  in  directing  the 
application  of  its  point,  and  serves  to  prevent  it  from 
slipping. 

When  the  labial  and  palatine  walls  of  the  cavity  are  very 
thin,  great  care  is  necessary  to  prevent  fracturing  them,  in 
introducing  and  consolidating  the  gold.  The  consolidating 
should  be  commenced  around  the  edges,  and  the  pressure 
applied  in  a  direction  towards  the  centre  of  the  cavity. 

It  sometimes  happens  that  the  caries  extends  forwards  to 
the  labial  and  ajiproximal  angle  of  the  tooth,  extending 
upwards,  at  the  same  time,  above  the  termination  of  the 
apex  of  the  gum.  Great  difiiculty  is  often  exjjerienced,  in 
cases  of  this  sort,  in  thoroughly  filling  this  portion  of  the 
cavity,  and  it  cannot  always  be  done  from  behind  the  tooth. 
In  this  case,  after  having  filled  the  cavity  in  the  manner  as 
already  described,  the  operator  may  take  a  position  on  the 
left  side  of  the  patient,  and  with  an  instrument  having  a 
wedge-shaped   [>oint,  bent  like  the  one  represented  in  Fio-. 


FILLING  SUPERIOR   INCISORS   AND   CUSPIDATI. 


315 


Fm.  89. 


89,  make  as  large  an  opening  as 
possible  in  the  gold.  This  done^  he 
may  grasp  the  left  lateral  incisor_,  or 
cuspid  tooth   with   his   thumb   and 

middle  finger  of  his  left  hand,  elevating  the  upper  lip  with 
the  fore-finger  of  tlie  same ;  then,  with  the  instrument  held 
in  his  right  hand,  in  the  manner  as  represented  in  Fig.  90, 
he  may  proceed  to  introduce  the  gold,  filling  the  upper 
part  of  the  opening  first.  After  introducing  fold  after  fold, 
until  it  is  completely  and  compactly  filled,  the  extruding 
portion  may  be  consolidated  with  a  similar  shaped  instru- 
ment, having  a  round  serrated  point,  or  an  instrument  like 
the  one  represented  in  Fig.  88. 

The  size  of  the  roll  of  gold  may  be  varied  to  suit  the 
size  of  the  cavity^  though  it  should  seldom  have  in  it  more 

Fig.  90. 


than  a  fourth  of  a  leaf  of  No.  4.  If  more  than  this  be  em- 
ployed at  one  time,  it  will  be  difficult  to  apply  them  suffi- 
ciently near  together. 

When  the  teeth  have  been  separated  by  pressure,  or  when 
the  aperture  is  as  wide  anteriorly  as  posteriorly,  the  gold 
may  be  introduced  from  either  side  as  may  best  suit  the 
convenience  of  the  operator  ;  but,  when  introduced  from 
before,  it  may  be  done  in  the  manner  as  just  described_,  the 
operator  standing  on  the  left  side  of  his  patient,  and  using 
such  instrument  as  he  may  find  best  adapted  for  its  intro- 


316 


FILLING  SUPERIOR   INCISORS   AND   CUSPID  ATI. 


diiction.  Sometimes  the  one  represented  in  Fig.  84,  will 
be  found  best  suited  to  the  purpose  ;  at  other  times,  the 
one  represented  in  Fig.  89  can  be  most  advantageously 
employed. 

The  gold  having  been  introduced  and  condensed^  the 
surface  of  the  filling  may  be  finished  in  the  manner  as 
already  described. 

In  describing  the  manner  of  filling  the  right  central  inci- 
sor in  the  left  approximal  surface,  it  will  not  be  necessary, 
as  the  method  of  procedure  is  so  very  similar  to  that  of  fill- 
ing the  left  in  the  right  side,  to  enter  so  minutely  into 
detail.  In  this  as  in  the  other  case,  the  gold,  as  a  general 
rule,  should  be  introduced  from  behind  the  tooth,  forwards 
and  upwards.  But  no  matter  from  which  side  it  is 
introduced,  the  operator  should  stand  on  the  right  side  of 
the  patient.  The  head  of  the  latter,  too,  should  have  the 
same  elevation,  and  the  same  inclination  backwards^  but 
the  face  should  be  turned  more  towards  the  operator  to  give 
him  a  better  view  of  the  cavity  in  the  tooth,  and  to  enable 
him  to  reach  it  more  readily  with  the  instrument. 

The  patient  being  seated,  the  cavity  formed,  cleansed, 
and  dried,  the  operator  may  proceed  to  introduce  the  gold 
in  the  manner  as  already  described,  with  an  instrument  like 
the  one  represented  in  Fig.  84.     In  many  cases,  however. 

Fig.  91. 


he  will  require  one  having  a  somewhat  longer  point,  and 
curved  to  nearly  a  right  angle  witli  the  stem.     But  what- 


FILLING   SUPERIOR  INCISORS  AND   CUSPID  ATI.  317 

ever  be  the  length  and  ciirvatiire  of  the  point,  the  instru- 
ment shoukl  be  held  somewhat  differently  in  the  hand,  (see 
Fig.  91,)  and  grasped  so  firmly  with  the  thumb,  and  fore 
and  middle  fingers,  as  to  prevent  it  from  rotating.  The 
head  should  be  securely  confined  with  the  left  arm,  the  up- 
per lip  elevated  with  the  thumb  of  the  hand  of  the  same, 
pressing  it  at  the  same  time  firmly  against  the  anterior  sur- 
face of  the  tooth.  The  middle  or  fore-finger,  as  may  best 
suit  the  convenience  of  the  operator,  of  the  same  hand,  may 
be  i^laced  on  the  gum  of  the  palatine  surface,  to  direct  the 
application  of  the  point  of  the  instrument,  prevent  the  lia- 
bility of  its  slipping,  and  control  the  free  end  of  the  roll  of 
foil.  The  lower  lip  may  be  depressed  either  with  the  mid- 
dle joint  of  this,  or  with  any  of  the  other  fingers. 

After  having  placed  one  end  of  the  gold  in  the  cavity, 
fold  after  fold  may  be  introduced,  as  before  directed,  un- 
til it  is  compactly  filled,  except  in  those  cases  where  the 
lower  part  is  very  small,  when,  after  having  filled  all  but 
this  portion,  a  smaller  pointed  instrument  should  be  em- 
ployed for  the  completion  of  the  operation,  and,  indeed,  for 
the  introduction  of  the  whole  of  the  gold  if  the  cavity  is 
not  large  or  the  aperture  between  the  teeth  very  narrow. 

For  consolidating  the  extruding  gold,  the  instrument  re- 
presented in  Fig.  87,  will,  in  many  cases,  be  all  that  is  re< 
quired.  But  in  addition  to  this,  others  are  often  needed. 
The  one  represented  in  Fig.  92,  can  sometimes  be  used  very 
advantageously.  The  one  in  Fig. 
93,  may  often  be  efficiently  employed  Fig.  92. 

in  some  parts  of  the  operation  of 
condensing  in  the  right,  as  well  as 
in  the  left  approximal  surface  of  an 
an  incisor,  or  cuspid  tooth.  Pio.  93. 

Both  of  the  last  mentioned  instru- 
ments may  often  be  used  to  great  ad- 
vantage on  the  approximal  surfaces 
of  other  teeth.  The  instruments  re- 
presented in  the  chapter  on  filling  teeth  with  crystalline  and 


318  FtLLING  SUPERIOR   IXCISORS   AND   CUSPID  ATI, 

sponge  gold,  Fig.  118,  may  also  be  advantageously  employ- 
ed in  consolidating  the  gold  in  the  approximal  surfaces  of 
the  incisors  as  well  as  in  other  teeth. 

The  gold  having  been  properly  introduced  and  consoli- 
dated, the  remaining  part  of  the  operation  may  be  com- 
pleted as  before  directed.  But  in  doing  this^  it  may  be  well 
to  observe^  that  while  it  is  important  that  every  particle  of 
gold  overlapping  the  orifice  of  the  tooth,  and  frequently  ex- 
tending under  the  free  edge  of  the  gum,  should  be  removed 
before  finishing  the  surface  of  the  filling.  The  operator 
ought,  at  the  same  time,  to  avoid  as  much  as  possible, 
wounding  the  point  of  the  gum  and  dental  periosteum. 

As  the  cavity  in  the  tooth  frequently  extends  not  only  to 
the  gum,  but  sometimes  a  little  above  it,  great  care  is  ne- 
cessary to  prevent  wounding  it,  and  indeed  there  are  many 
cases,  in  which  it  cannot  be  avoided^  unless  the  dentist  uses 
the  precaution  to  press  the  point  of  it  up  between  the  teeth, 
by  the  introduction  of  a  piece  of  raw  cotton^  or  gum  elastic, 
a  day  or  two  before  the  operation  of  filling  is  performed. 

In  filling  an  incisor,  or  cuspid  tooth  in  the  labial  surface, 
the  operation  is  often  very  simple,  and  easy  of  performance, 
but  there  are  many  cases  in  which  it  is  both  difficult  and 
tedious.  The  head  of  the  patient  should  rest  upon  the 
head-piece  of  the  chair,  with  his  face  upward  in  the  manner 
as  already  described,  and  sustained  in  the  same  way  with 
the  left  arm  of  the  operator,  while  with  the  thumb  of  the 
hand  of  the  same  placed  on  the  gum  above  the  tooth,  the 
upper  lip  should  be  elevated. 

Pjq  9^  The  fore-finger  may  be  pressed  firm- 

\j  against  the  palatine  surface  of  the 
tooth,  and  the  left  side  of  the  chin 
gently  grasped  with  the  middle,  an- 
nular and  little  fingers.  Then  with  an  instrument,  like 
the  one  represented  in  Fig.  94,  having  a  wedge-shaped 
point,  grasped  with  the  right  hand,  in  the  manner  as  seen 
in  Fig.  91,  or  95,  as  may  be  most  convenient,  the  operator 
may  proceed  to  introduce  the  gold,  standing  at  the  right 


FILLING  SUPERIOR  INCISORS  AND   CUSPID  ATI. 


319 


side  of  tlie  patient,  with  the  thumb  of  the  right  hand  rest- 
ing on  a  tooth  to  the  left  of  the  one  he  is  about  to  fill,  or 
against  the  cheek,  he  should  commence  by  laying  the  first 
folds  against  the  wall  of  the  cavity  nearest  to  him,  and  thus 
introduce  fold  after  fold,  until  it  is  thoroughly  and  com- 

FiG.  95. 


^■^^.■i^t 


'».iM 


te^^'o-^-" 


pactly  filled.  The  extruding  portion  may  be  consolidated 
with  a  round  or  square  pointed  instrument  having  the  same 
bend,  or  with  a  straight  pointed  one  as  represented  in  Fig. 
96.  But  in  this  part  of  the  operation,  great  care  is  neces- 
sary to  prevent  the  instrument  from  slipping  and  wound- 
ing the  gums.  After  having  partially  consolidated  the 
gold,  the  overlapping  portion  may  be  firmly  pressed 
towards  the  orifice  of  the  cavity,  then  Fig.  oc. 

the  point  of  the  instrument  should  be 
repeatedly  applied  to  every  part  of  the 
surface  of  the  filling,  until  it  can  no  longer  be  made  to  yield 
to  pressure.  This  done,  the  gold  may  be  filed  down  to  a 
level  with  the  surface  of  the  tooth,  ground  with  Arkansas 
oil-stone,  and  burnished  or  polished. 

When  the  cavity  is  shallow  and  the  orifice  broad,  the 
gold  as  it  is  introduced  must  be  held  in  place,  with  the 
thumb  of  the  left  hand,  until  a  sufficient  quantity  has  been 
placed  in  the  cavity  to  obtain  for  it  the  necessary  support 
from  the  surrounding  walls.  But  in  overcoming  difficulties 
of  this  sort,  the  peculiar  circumstances  of  the  case  can  alone 
suggest  the  proper  means  to  be  employed  by  the  operator. 


320  FILLING  SUPERIOR   INCISORS   AND   CUSPIDATI. 

The  decay  sometimes  extends  entirely  across  the  labial 
surface  of  the  tooth,  leaving,  after  its  removal,  a  horizontal 
groove  open  at  both  ends.  In  this  case,  the  walls  should 
be  made  rough,  or  wider  at  the  bottom  than  at  the  opening, 
and  the  operation  of  filling  commenced  at  one  end,  by  apply- 
ing the  folds  of  foil,  first,  against  either  the  upper  or  lower 
wall,  as  may  best  suit  the  convenience  of  the  operator,  and 
carrying  them  across  to  the  other,  and  consolidating  them 
so  thoroughly  as  to  prevent  the  liability  of  their  being  dis- 
placed during  any  subsequent  part  of  the  operation.  An- 
other and  another  series  of  folds  are  introduced  in  the  same 
manner  as  the  first,  and  each  in  close  contact  with  the  pre- 
ceding series,  until  the  groove  is  completely  filled,  applying 
the  pressure  during  the  whole  of  this  part  of  the  operation 
in  the  direction  of  the  two  walls.  In  condensing  the  ex- 
truding gold,  the  operator  may  commence,  first  at  one  end 
of  the  groove,  then  at  the  other,  and  afterwards  proceed 
with  the  process  of  consolidating  over  the  whole  surface  of 
the  filling. 

In  finishing  the  operation,  the  same  precaution,  with  re- 
gard to  wounding  the  gum  and  dental  j)eriosteum,  should 
be  observed  here  as  recommended  for  the  approximal  sur- 
face of  the  tooth. 

Although  it  rarely  happens  that  the  palatine  surfaces  of 
the  upper  incisors  are  attacked  b}"  caries,  yet  the  disease 
does  sometimes  develop  itself  there,  in  the  indentations  oc- 
casionally found  a  little  below  the  free  edge  of  the  gum. 

But  the  removal  of  the  diseased  part,  the  formation  of  a 
cavity^  and  the  introduction  of  a  filling,  can,  in  the  majori- 
ty of  cases,  be  more  easily  accomplished  in  this,  than  in  any 
other  part  of  an  incisor  tooth. 

The  cavity  being  properly  prepared  for  the  reception  of 
the  filling,  and  the  head  placed  as  before  directed,  except 
that  the  chin  may  be  a  little  more  elevated,  to  enable  the 
operator  to  obtain  a  more  convenient  view  of  the  locality  of 
his  operation,  the  thumb  of  the  left  hand  may  be  placed  on 
the  labial  surface  of  the  tooth,  and  the  fore-finger  on  the 


FILLING   SUPERIOR   MOLARS   AND   BICUSPIDS.  321 

gum  immediately  above  the  palatine  surface.    He  may  now, 
with  a  wedge-pointed  instrument,  shaped  like  the  one  repre- 
sented in  Fig.  97,  proceed  to  introduce  the  gold,  applying 
the  first  fold  against  the  palatine  wall 
of  the  cavity,  or  the  palato-approximal  ^^^'  ^^* 

angle  of  the  wall,  as  may  be  most  con- 
venient. Having  filled  the  cavity,  the 
extruding  gold  may  be  condensed  with  Fig.  98. 

an  instrument  like  the  one  represented 
in  the  annexed  cut.     See  Fig,  98. 

Sometimes  straight  instruments,  and  at  other  times  in- 
struments curved  at  the  points  more  than  those  represented 
in  Figs.  97  and  98,  can  be  more  efficiently  and  conveniently 
employed,  depending  altogether  upon  the  size  of  the  mouth 
and  the  forward  or  backward  deviation  of  the  teeth  from  a 
vertical  arrangement  in  the  jaw.  This  is  a  matter,  there- 
fore, which  the  judgment  of  the  operator,  in  view  of  the  pe- 
culiarities of  the  case,  can  alone  determine. 

FILLING  THE  SUPERIOR  MOLARS  AND  BICUSPIDS. 

In  describing  the  manner  of  filling  a  cavity  in  each  of  the 
principal  localities  liable  to  be  attacked  by  caries,  in  the 
above  mentioned  teeth_,  the  writer  will  begin  with  the  grind- 
ing surface  of  the  first  molar  on  the  right  side.  The  direc- 
tions he  will  give  with  regard  to  the  manner  of  filling  a  cavity 
here,  with  a  few  exceptions,  will  be  applicable  to  the  intro- 
duction of  a  filling  in  the  grinding  surface  of  any  of  the 
upper  molars  or  bicuspids. 

When  the  cavity  is  very  deep,  and  its  circumference  not 
very  large,  it  is  difficult,  if  not  impossible,  to  make  a  filling 
sufficiently  firm  and  solid  in  every  part  by  the  introduction 
of  folds  of  gold  long  enough  to  extend  from  the  bottom  to 
the  orifice.  The  operation_,  therefore,  should  be  divided 
into  two  parts ;  namely,  the  upper  half  or  two-thirds  of  the 
cavity  should  be  first  thoroughly  filled,  and  afterwards  the 
remaining  lower  part,  with  vertical  folds. 


322  FILLING  SUPERIOR   MOLARS   AND  BICUSPIDS. 

In  filling  a  molar  or  bicuspid  in  any  of  its  surfaces,  the 
head  of  the  patient  should,  for  the  most  part,  occupy  very 
nearly  the  same  position,  and  have  the  same  elevation  as 
required  for  the  performance  of  the  operation  on  an  incisor 
or  cuspidatus.  The  cavity  being  prepared  for  the  filling, 
and  one  end  of  the  roll  of  foil  placed  in  it,  the  tooth  may  be 
grasped  with  the  thumb  and  fore-finger  of  the  left  hand  of 
the  operator — the  former  placed  on  the  buccal  surface  in 
such  a  manner  as  to  press  back  the  commissure  of  the  lips, 
and  the  latter  on  the  palatine  surface,  then  fold  after  fold 
may  be  introduced  and  forcibly  pressed  against  the  posterior 
wall  until  the  cavity  is  filled.  For  this  purpose  an  instru- 
ment may  be  used  like  the  one  represented  in  Figs.  94,  or 
96,  as  may  best  suit  the  convenience  of  the  operator.  If 
the  former  is  used,  it  may  be  grasped  as  shown  in  Fig.  91. 
After  which  the  extruding  portion  may  be  condensed  with 
a  straight  instrument  like  the  one  represented  in  Figs.  96, 
98  or  99,  as  may  be  most  convenient. 

As  a  general  rule,  filling  a  cavity  in  the  grinding  surface 
of  an  upper  molar  or  bicuspid  is  an  exceedingly  simple  ope- 
ration, requiring  less  skill  than  the  introduction  of  a  plug 
in  any  other  locality  in  these  teeth,  but  there  are  cases 
In  which  it  is  rendered  very  difficult ;  as  for  example,  when 
there  are  one  or  more  fissures  or  carious  depressions  radia- 
ting from  the  main  cavity.  To  fill  these  thoroughly,  after 
the  diseased  parts  have  been  removed,  which  last  is  often  a 
very  tedious  operation,  requires  considerable  time  and  skill. 
When  it  is  not  joroperly  done,  as  is  too  often  the  case,  a  re- 
currence of  the  disease  will  soon  take  jjlace,  and  thus  defeat 
the  object  for  which  the  operation  is  performed. 

The  introduction  of  a  filling  in  the  fig.  99. 

grinding  surface  of  the  second  or  third 
molar  of  a  person  having  a  very  small 
mouth,  is  sometimes  attended  with  great 
difficulty,  and  in  some  cases,  can  only 
be  done  with  an  instrument  having  a 
point  bent  at  nearly  right  angles  with  the  stem,  like  the 


I 


FILLING  SUPERIOR  MOLARS   AND   BICUSPIDS.  323 

one  represented  in  Fig.  99,  consequently  the  power  required 
for  introducing  and  consolidating  the  gold  is  applied  to 
great  disadvantage.  But  the  instrument  represented  in  this 
cut  is  only  intended  for  the  first  part  of  the  operation  of 
consolidating  the  metal.  For  the  completion  of  even  this, 
smaller  points  are  required. 

In  filling  a  cavity  in  the  grinding  surface  of  a  first  upper 
molar  on  the  left  side  of  the  mouth,  the  thumb  of  the  left 
hand  may  be  placed  against  the  left  cuspid  or  first  or  second 
bicuspid  as  may  be  most  convenient  to  the  operator,  while 
the  fore-finger  is  placed  behind  the  point  of  the  instrument, 
and  at  the  same  time  made  to  push  back  the  commissure  of 
the  lips.  To  obtain  a  good  view  of  the  cavity  in  a  second  or 
third  molar  during  the  operation,  the  cheek  should  be 
pressed  from  the  tooth  with  the  fore-finger  of  the  left  hand, 
but  this  finger  can  seldom  be  carried  far  enough  back  on 
this  side  of  the  mouth  to  be  placed  behind  the  point  of  the 
instrument.  During  the  introduction  of  the  gold,  the  an- 
nular and  little  fingers  of  the  right  hand  should  be  made  to 
rest  on  the  incisor  teeth,  while  the  instrument  is  grasped 
with  the  thumb,  middle  and  fore-finger  in  the  manner  as 
seen  in  Fig.  91. 

In  filling  a  cavity  in  the  anterior  approximal  surface  of  a 
right  superior  molar  or  bicuspid,  the  operation  may  be  com- 
menced by  placing  the  gold  against  the  palatine  wall,  and 
ending  at  the  buccal.  But  before  the  process  of  condensing 
is  commenced,  every  portion  of  the  surface  ought  to  be  thor- 
oughly tested  with  a  wedge-pointed  instrument,  and  wher- 
ever the  point  can  be  forced  into  the  gold,  the  cavity  thus 
formed  should  be  filled.  The  instrument  employed  for  the 
introduction  of  the  gold  may  be  like  the  one  represented  in 
Fig.  84,  but  having  a  rather  longer  point;  and  grasped  in 
the  manner  as  represented  in  Fig.  91.  For  condensing  the 
extruding  portions,  either  or  both  of  the  instruments  repre- 
sented in  Figs.  8G,  and  92  may  be  used,  as  also  the  one 
employed  for  the  introduction  of  the  gold ;  and  one  like  the 
following,  see  Fig.  100,  may  be  sometimes  used  with  great 


324 


FILLING   SUPERIOR   MOLARS   AND   BICUSPIDS. 


advantage.     During  this  part  of  the  operation,  the  instrn- 

FiG.  100.  ment  may  be  held  in  the  manner  as 

last  represented,  or  as  seen  in  Fig. 

101.    A  much  greater  amount  of  force 

can  be  applied  when  it  is  held  in  this  manner  than  in  the 

other. 

FiQ.  101,  Nearly  the  same  method  of 

procedure,  and  the  same  in- 
struments are  required  for  fill- 
ing a  tooth  in  the  same  sur- 
face on  the  opposite  side  of 
the  jaw.  When  practicable, 
the  fore-finger  of  the  left 
hand  should  be  placed  on  the 
palatine  surface  of  the  tooth, 
and  the  thumb  against  the 
buccal  surface,  and  in  addi- 
tion to  the  instruments  re- 
commended for  the  right  side 
of  the  mouth,  the  one  represented  in  Fig.  86  may  be  very 
conveniently  employed  in  introducing  the  gold,  as  can  also 
Fio.  102.  one  like  Fig.  88,  or  the  following,  Fig. 

=::v  102,  in  condensing  the  surface  of  the 
filling.  The  writer  finds  this  last  par- 
ticularly valuable  in  very  many  cases. 
A  cavity  in  the  posterior  approximal  surface  of  a  bicuspid 
in  the  superior  maxillary  of  either  side  of  the  mouth,  can, 
in  the  majority  of  cases,  be  as  easily  filled  as  one  in  the  an- 
terior approximal  surface.  The  position  of  the  left  hand  is 
very  nearly  the  same^  and  in  the  introduction  of  the  gold, 
the  first  folds  are  placed  against  the  palatine  wall  of  the 
cavity.  By  commencing  the  operation  on  this  side,  the 
operator  is  enabled  to  lay  the  folds  more  compactly  than  he 
could,  were  he  to  commence  at  any  other  part.  He  also 
has  a  more  perfect  control  over  the  instrument  he  employs 
in  this  part  of  the  operation,  and,  besides,  it  affords  him  a 
better  view  of  the  cavity  during  the  introduction  of  the 


FILLING  SUPERIOR   MOLARS   AND   BICUSPIDS.  325 

gold.  For  consolidating  the  filling,  the  instruments  repre- 
sented in  Figs.  87,  88  and  93,  are^  perhaps,  as  well  adapted 
to  the  purpose  as  any  that  can  be  employed. 

When  the  mouth  of  a  patient  is  large,  a  filling  can  often 
he  introduced  with  nearly  as  much  ease  and  convenience,  in 
the  posterior  approximal  surface  of  a  first,  or  even  a  second 
upper  molar,  as  in  the  same  surface  of  a  bicuspid ;  but  when 
the  mouth  is  small  and  the  cheeks  fleshy,  it  often  becomes 
an  exceedingly  diflScult  and  perplexing  operation.  Although 
the  same  method  of  jjrocedure  is  used,  yet,  as  it  is  absolute- 
ly necessary  to  the  introduction  of  a  good  filling,  that  the 
operator  see  the  cavity  and  witness  every  part  of  the  opera- 
tion ;  his  ingenuity  is  often  taxed  to  the  utmost,  in  contriv- 
ing the  most  suitable  means  to  enable  him  to  do  it.  A 
number  of  instruments  for  drawing  back  the  corner  of  the 
mouth  have  been  invented  ;  but,  after  all,  the  writer  be- 
lieves there  are  none  so  well  suited  to  the  purpose,  as  the 
thumb  or  fore-finger  of  the  left  hand  of  the  operator. 

Before  dismissing  this  part  of  the  subject,  there  is  one 
point  to  which  the  attention  of  the  young  practitioner 
should  be  particularly  directed.  The  part  of  the  opera- 
tion in  which  many,  in  other  respects  tolerably  good  opera- 
tors, are  most  likely  to  fail,  is,  in  not  introducing  a  sufficient 
quantity  of  gold  in  the  upper  palatine  portion  of  the  cavity. 
The  author  frequently  meets  with  cases  in  which  every  other 
part  of  the  filling  is  well  consolidated^,  and  the  walls  of  the 
cavity  perfectly  sound  in  every  other  place  but  this,  and 
which,  upon  the  application  of  a  wedge-pointed  instrument 
is  easily  perforated.  He  would,  therefore,  advise  the  inex- 
perienced operator  to  thoroughly  test  this  by  severe  pressure 
with  a  sharp  wedge-pointed  instrument,  as  well,  indeed,  as 
every  other  part  of  the  filling,  before  leaving  the  operation. 
There  is  also  one  other  precaution  that  should  be  attended 
to,  and  this  remark  will  apply  with  as  much  force  to  fillings 
in  the  approximal  surfaces  of  the  incisors  and  cuspids  as  to 
the  molars  and  bicuspids ;  it  relates  to  overlapping  portions 
of  gold  on  the  side  of  the  tooth  under  the  free  edge  of  the 


326  FILLING   SUPERIOR    MOLARS   AND   BICUSPIDS. 

gum.     These  must   be   carefully  and  completely   removed 
before  the  operation  can  be  regarded  as  complete. 

In  filling  a  cavity  in  the  buccal  surface  of  an  uj^per  bicus- 
pid or  molar,  on  either  side  of  the  mouth,  the  gold  may  be 
introduced  with  an  instrument  like  the  one  represented  in 
Fig.  84,  or  Fig.  94,  as  may  best  suit  the  convenience  of  the 
operator.  The  latter  is  better  adapted  for  the  left  side,  and 
may  also  be  used  on  the  right.  The  straight  wedge-point- 
ed instrument  too,  may  be  advantageously  employed  on 
this  side.  In  the  introduction  of  the  gold,  the  first  folds 
should  be  placed  aganist  the  posterior  wall,  and  thus  this 
part  of  the  operation  may  proceed  from  behind  forwards, 
pressing  the  folds  against  each  other  as  compactly  as  pos- 
sible. 

When  the  cavity  has  a  large  orifice,  and  is  rather  shallow, 
or  in  other  respects  badly  shaped  for  the  retention  of  the 
gold,  the  operation  is  often  tedious,  difficult  and  perplexing. 
But  under  favorable  circumstances,  a  filling  may  be  as  read- 
ily introduced  here  as  in  almost  any  other  part. 

The  palatine  surface  of  a  bicuspid  is  rarely  attacked  by 
caries  nor  does  the  disease  very  frequently  develop  itself  on 
this  side  of  a  molar,  and  when  it  does,  it  is  usually  seated  in 
a  depression  at  the  termination  of  a  fissure  leading  from  the 
posterior  depression  in  the  grinding  surface.  The  depres- 
sion first  mentioned  is  usually  situated  near  the  posterior 
palato-approximal  angle  of  the  crown  about  equidistant  from 
the  gum  and  the  coronal  extremity  of  the  tooth.  It  some- 
times happens  that  the  walls  of  these  fissures  are  affected 
with  caries  throughout  their  whole  extent,  requiring,  after 
the  removal  of  the  diseased  part,  a  filling  reaching  from  the 
depression  in  the  grinding,,  to  its  termination  on  the  pala- 
tine surface.  In  this  case,  the  portion  of  the  cavity  on  the 
grinding  surface  may  be  first  filled,  then  the  operator  may 
proceed  to  fill  that  portion  of  it  in  the  jmlatine  surface,  in 
the  same  manner  as  if  it  were  a  simple  cavity,  placing 
the  first  folds  of  foil  against  the  upper  and  posterior  side  of 
the  opening,  if  it  be  in  a  tooth  on  the  right  side   of  the 


I 


FILLING   SUPERIOR   MOLARS   AND   BICUSPIDS. 


327 


montlij  with  an  instrument  like  the  one  reiiresented  in  Fig. 
94.  But  in  doing  this,  great  care  is  necessary  to  prevent 
the  instrument  from  slipping.  It  often  hajipens,  too^  that 
the  orifice  becomes  choked  with  foil  before  the  cavity  is  half 
filled.  This,  indeed,  is  liable  to  occur  in  filling  any  cavity 
in  any  tooth,  and  when  it  does  happen,  unless  a  sufficient 
amount  of  pressure  is  applied  to  make  a  free  opening  into 
it,  the  filling  will  be  imperfect,  and  the  object  of  the  oper- 
ation wholly  defeated.  When  the  cavity  is  situated  in  a  left 
molar,  the  gold  may  be  introduced  with  an  instrument  like 
the  one  represented  in  Fig.  84,  or  97,  as  may  be  most  con- 
venient, placing  the  first  folds  against  the  upper  wall  of  the 
cavity,  and  proceeding  from  thence  towards  the  lower. 

The  curvatures  of  the  points  of  the  condensing  instru- 
ments may  be  similar  to  those  employed  for  the  introduc- 
tion of  the  gold.  The  process  of  condensing  the  extruding 
portion  of  a  filling  in  the  buccal  or  palatine  surface  of  a 
molar,  as  well  as  in  the  approximal  surface  of  almost  any 
isolated  tooth,  may  be  greatly  aided  with  properly  con- 
structed forceps.      The  following  cut  will  convey  a  more 

Fig.  103. 


correct  idea  of  their  construction  than  any  description  that 
can  be  given.  They  are  provided  with  both  straight  and 
curved  points,  see  Fig.  103,  «,  h,  c,  and  used  by  placing 
the  flat  jaw,  covered  with  raw  cotton  or  a  cushion,  against 
the  sound  side  of  the  tooth,  and  the  condensing  point  against 
the  filling,  which  is  made  to  act  on  it  by  pressing  the  han- 
dles towards  each  other.  In  this  way  as  much  pressure 
may  be  exerted  upon  the  .filling  as  the  tooth  will  bear.     It 


328         FILLING   THE  INFERIOR   INCISORS   AND   CUSPID  ATI. 

is  only,  however,  in  tlie  fewest  number  of  cases  that  this 
instrument  can  be  advantageously  employed.  The  credit  of 
the  invention,  it  is  believed,  belongs  to  the  late  Dr.  H.  H. 
Hay  den. 

A  tubercle,  of  greater  or  less  size,  is  sometimes  found  on 
the  anterior  palatial  part  of  the  surface,  near  the  coronal 
extremity  of  the  tooth.  Between  this  and  the  body  of  the 
crown,  a  deep  depression  is  often  seen,  which  becomes  the 
seat  of  caries,  but  the  removal  of  the  diseased  part,  and  the 
introduction  of  a  filling  is  so  simple,  that  a  special  descrip- 
tion of  the  operation  is  not  deemed  necessary. 

FILLING  THE  IiNFERIOR  INCISORS  AND  CUSPIDATI. 

The  operation  of  filling  a  lower  incisor  or  cuspidatus,  is, 
by  far,  more  difficult  than  filling  an  upper.  It  is  fortunate, 
therefore,  both  to  the  dentist  and  mankind  generally,  that 
the  incisors  and  cuspidati  of  the  lower  jaw,  are  less  liable  to 
be  attacked  by  caries  than  the  upper. 

The  constant  tendency  of  the  lower  jaw  to  move  and 
change  its  position,  is  embai-rassing  to  the  dentist  in  operat- 
ing on  any  of  the  teeth  in  it,  and  on  the  incisors  and  cuspi- 
dati it  is  sometimes  peculiarly  perjilexing.  To  prevent 
this,  all  the  effort  the  operator  can  exert  with  his  left  hand, 
is  frequently  required.  From  the  backward  inclination, 
too,  of  these  teeth,  it  rarely  happens  that  the  gold  can  be 
introduced  from  the  lingual  side  of  the  arch,  consequently, 
it  is  necessary  to  make  the  aperture  as  wide  anteriorly  as  pos- 
teriorly. But  as  these  teeth  are,  comparatively,  very  small, 
the  separation  when  made  with  a  file,  should  be  no  wider 
than  is  absolutely  necessary  for  the  removal  of  the  diseased 
part  and  the  introduction  of  the  gold.  AVhen,  however,  it 
can  be  done  with  safety,  the  separation  may  be  made  by  the 
introduction  of  a  piece  of  gum  elastic  or  other  substance 
between  the  teeth,  in  the  manner  as  before  described. 

But  before  we  proceed  further  it  may  be  well  to  remark, 
that  while  operating  on  the  teeth  of  the  lower  jaw,  the  head 


FILLING  THE  INFERIOR  INCISORS  AND  CUSPIDATI.         329 

of  tlie  patient  should  occupy  a  more  perpendicular  position 
than  while  operating  on  those  of  the  upper,  and  it  may  be 
made  to  do  this,  either  by  lowering  the  seat  or  raising  the 
head-piece  of  the  chair.  When  by  the  latter,  it  will  be 
occasionally  necessary  for  the  operator  to  stand  upon  a  stool 
five  or  six  inches  in  height. 

In  filling  a  cavity  in  the  right  approximal  surface  of  a 
lower  incisor  or  cuspidatus,  the  following  method  of  proce- 
dure may  be  adopted.  The  cavity  being  prepared,  and  a 
sujQficient  quantity  of  gold  foil  to  fill  it  made  into  a  small 
roll,  or  folded  lengthwise  as  the  operator  may  prefer,  with 
the  left  arm  over  the  patient's  head,  the  chin  is  gently 
grasped  with  the  hand  of  the  same,  while  the  thumb  is 
placed  against  the  lingual  surface  of  the  tooth — the  fore- 
finger serving  to  direct  the  gold  and  point  of  the  instru- 
ment, and  to  also  depress  the  lower  lip.  The  folds  of  gold 
in  their  introduction  are  pressed  firmly  against  the  lower 
wall  of  the  cavity.  The  instrument  employed  for  this  pur- 
pose may  be  shaped  like  the  one  represented  in  Fig.  104, 
with  a  very  small  wedge-shaped  point,  ^^^  ^^^ 

and  held  in  the  right  hand;,  in  the  man- 
ner as  seen  in  Fig.  91.     The  consolida-  ^^jiJE:^_ 
tion  of  the  extruding  gold  may  be  effect- 
ed, partly  with  the   same  instrument,  partly  with  a  round 
pointed  one,  in  other  respects  shaped  like  the  one  shown  in 
Fig.  105^  and  partly  with  an  instru-  fig.  io5. 

ment  shaped  like  the  one  represented  ^^^^ 
in  Fig.  93.  But  in  this  part  of  the 
operation  the  tootli  should  be  firmly  held  between  the 
thumb  and  fore-finger  of  the  left  hand,  to  prevent  it  from 
being  moved  in  its  socket  by  the  pressure  of  the  instru- 
ment. 

When  the  incisors  are  very  small,  and  the  caries  has 
spread  over  a  large  portion  of  the  side  of  the  tooth,  it  is 
often  difiicult  to  form  a  suitable  cavity  for  the  retention  of  a 
filling,  without  penetrating  to  the  pulp  cavity.  In  cases  of 
this  sort,  the  patience  and  skill  of  the  operator  are  fre- 
22 


330  FILLING   THE   INFERIOR   MOLARS   AND   BICUSPIDS. 

quently  taxed  severely  in  obtaining  a  sufficiently  secure 
suj^port  for  the  gold.  But  this  he  can  usually  do,  if  he  can 
make  the  bottom  of  the  cavity  as  large  as  the  orifice,  even 
though  it  have  but  little  depth. 

The  manner  of  introducing  a  filling  in  the  left  approxi- 
mal  surface,  is  so  very  similar,  it  is  scarcely  necessary  to 
give  a  separate  description  of  the  method  of  doing  it.  The 
left  arm  and  hand,  as  well  as  the  thumb  and  fore-finger  are 
all  disposed  of  in  the  manner  as  just  described.  The  same 
instruments,  too,  may  be  employed  for  introducing  and 
consolidating  the  gold,  though,  in  the  first  part  of  the  ope- 
ration, the  instrument  rej^resented  in  Fig.  89,  may  often  be 
advantageously  substituted  for  the  one  represented  in  Fig. 
104. 

Thus  far,  nothing  has  been  said  with  regard  to  the  intro- 
duction of  a  filling  in  the  labial  or  lingual  surface  of  either 
of  the  two  classes  of  teeth  now  under  consideration.  Al- 
though caries  rarely  attacks  either  of  these  surfaces  of  a 
lower  incisor,  it  does  sometimes  develop  itself  in  the  labial 
surface  of  a  cuspidatus,  but  the  operation  of  introducing  a 
filling  here  is  so  simple,  that  a  separate  description  of  the 
manner  of  performing  it  is  not  deemed  necessary. 

FILLLNG  THE  INFERIOR  MOLARS  AND  BICUSPIDS. 

In  filling  a  cavity  in  the  grinding  surface  of  a  lower 
molar  or  bicuspid  on  the  right  side  of  the  mouth,  the  operator 
may  stand  on  the  same  side  of  his  patient,  and  a  few 
inches  higher  than  while  operating  on  an  incisor  or  cuspi- 
datus. With  his  left  arm  placed  over  his  patient's  head, 
the  tooth  may  be  grasped  with  the  thumb  and  fore-finger  of 
the  hand  of  the  same,  while  the  middle  finger  is  placed  by 
the  side  of  the  chin,  the  other  two  should  be  placed  beneath 
it.  The  gold  may  now  be  introduced  with  an  instrument 
like  the  one  represented  in  Fig.  97,  and  held  in  the  manner 
as  shown  in  Fig.  91,  pressing  the  folds  against  the  poste- 
rior wall  of  the  cavity. 


PILLING   THE   INFERIOR  MOLARS  AND   BICUSPIDS.  331 

In  condensing  the  gold  after  the  cavity  is  filled,  an  in- 
strument may  he  employed  like  the  one  represented  in  Fig. 
98.  Sometimes,  however,  an  instrument  like  the  one  shown 
in  Fig.  100,  which  may  he  held  in  the  manner  as  seen  in 
Fig.  85  ;  hut  a  greater  amount  of  force  can  he  exerted  when 
held  in  the  manner  as  represented  in  Fig.  101,  previously 
wrapped  with  the  corner  of  a  napkin,  to  prevent  the  small 
part  of  the  instrument  from  hurting  the  little  finger.  The 
kind  of  instrument,  and  the  manner  of  holding  it,  will, 
after  all,  have  to  he  determined  hy  the  operator.  But  dur- 
ing the  introduction  and  consolidation  of  the  gold,  the  lower 
jaw  should  he  firmly  held  with  the  left  hand  of  the  opera- 
tor, to  prevent  it  from  moving  and  from  heing  too  much 
depressed.  This  precaution  is  the  more  necessary,  as  the 
muscles  of  the  lower  jaw  and  ligaments  of  the  temporo- 
maxillary  articulation  are  seldom  strong  enough  to  resist 
the  amount  of  force  required  in  the  operation. 

In  filling  a  cavity  in  the  grinding  surface  of  a  tooth  on 
the  left  side,  the  dentist  may  sometimes  operate  to  greater 
advantage  hy  standing  on  the  same  side.  In  this  case,  the 
commissure  of  the  lips  may  be  pressed  hack  with  the  thumb 
of  the  left  hand,  placing  it  on  or  against  the  tooth  to  be  filled, 
while  the  fore-finger  may  pass  in  front  of  the  chin,  and  the 
other  three  beneath  it.  As  a  general  rule,  however,  he 
will  be  able  to  operate  more  conveniently  by  standing  on 
the  right  side  of  his  patient,  and  holding  the  tooth  and  chin 
in  the  manner  as  before  directed.  But,  in  either  case,  the 
gold,  in  its  introduction,  should  be  pressed  against  the  pos- 
terior wall  of  the  cavity. 

The  foregoing  general  directions,  will,  for  the  most  part, 
be  found  applicable  to  the  introduction  of  a  filling  in  the 
approximal  surfaces  of  the  teeth  under  consideration. 
When  the  crowns  of  these  are  long,  and  the  cavity  situ- 
ated near  the  gum,  the  operation  is  sometimes  very  dif- 
ficult and  tedious,  requiring  all  the  patience  and  skill  the 
dentist  can  exercise  to  accomplish  it  in  such  a  manner  as  to 
secure  the  object  for  which  it  is  performed.     And  this  diffi- 


332  FILLING   THE   INFERIOR   MOLARS   AND   BICUSPIDS. 

culty  is  increased  when  the  shape  of  the  cavity  is  unfavora- 
ble for  the  retention  of  the  gold  ;  or^  in  other  words,  when 
the  cavity  is  shallow  and  has  a  large  orifice.  There  is  also 
another  very  serious  difficulty  which  the  operator  frequently 
encounters  in  the  introduction  of  a  filling  in  the  approxi- 
mal,  as  well  as  in  the  buccal  surface  of  a  lower  molar  or 
bicuspid.  It  is  this  :  the  flow  of  saliva  is  often  so  profuse 
that  the  whole  of  the  lower  part  of  the  mouth  is  completely 
filled,  and  the  tooth  inundated  before  it  is  possible  to  intro- 
duce a  sufficient  quantity  of  gold  to  fill  the  cavity.  This 
not  only  retards  the  operation,  but  it  also  renders  it  more 
difficult  and  perplexing,  for  it  is  necessary  to  force  out  every 
particle  of  moisture  from  the  cavity  and  from  between  the 
difi'erent  layers  of  gold  before  the  necessary  cohesive  attrac- 
tion between  them  can  be  secured.  If  this  is  not  done,  or 
at  any  rate,  if  all  the  moisture  is  not  forced  from  the  cavity, 
and  the  gold  sufficiently  consolidated  to  render  it  imperme- 
able to  the  fluids  of  the  mouth,  the  operation  will  be  unsuc- 
cessful. 

For  the  purpose  of  obviating  the  last  mentioned  difficulty, 
a  variety  of  means  have  been  proposed,  but  the  one  princi- 
pally relied  on,  consists  in  placing  the  corner  of  a  soft  fine 
linen  napkin,  or  what  is  still  better,  fine  tissue  or  bibulous 
paper,  on  each  side  of  the  tooth,  so  as  to  form  a  sort  of  dam 
or  wall  around  it.  This  may  sometimes  be  successfully 
done,  but  in  many  cases  it  will  fail  to  accomplish  the  object, 
as  it  always  increases  the  flow  of  saliva,  and  is  more  or  less 
embarrassing  to  the  operator. 

In  the  introduction  of  the  gold,  it  may  be  pressed  against 
the  buccal  wall  of  the  cavity  on  the  right  side,  and  against 
the  lingual  wall  on  the  left  side.  Either  of  the  instruments 
represented  in  Figs.  84  and  94,  as  may  be  best  adapted  to 
the  peculiarities  of  the  case,  may  be  employed  for  the  intro- 
duction of  the  gold,  whether  the  cavity  be  situated  in  the 
anterior  or  posterior  approximal  surface  of  the  tooth,  and 
it  may  be  held  in  the  hand  in  the  manner  as  shown  in 
Fig.  91. 


FILLING   THE   INFERIOR  MOLARS   AND   BICUSPIDS.  6 

In  filling  a  cavity  in  the  lingual  and  posterior  approxi- 
mal  angle  of  a  first  or  second  left  bicuspid,  and  especiallj' 
after  the  loss  of  the  tooth  behind  it,  and  there  is  a  backward 
inclination  of  the  organ,  great  care  is  necessary  to  prevent 
the  instrument  from  slipping  and  wounding  the  lower  lip. 
The  most  convenient  position  for  the  operator  in  this  case  is 
on  the  left  side  and  partly  in  front  of  the  patient.  The 
tooth  may  theu  be  firmly  grasped  between  the  thumb  and 
fore-finger  of  the  left  hand_,  or  only  the  thumb  pressed 
against  the  buccal  surface  of  it,  as  the  ojDcrator  may  prefer, 
but  in  eitlier  case  it  may  be  used  as  a  rest  for  the  annular 
finger  of  the  right  hand,  during  the  introduction  and  con- 
solidation of  the  gold.  But  the  locality  of  the  cavity  is 
such,  especially  when  the  mouth  of  the  patient  is  small, 
that  it  can  only  be  seen  with  great  difficulty.  Hence  the 
operator  is  constantly  liable  to  place  the  point  of  the  instru- 
ment on  one  side  of  the  orifice  against  an  overlapping  por- 
tion of  gold,  which,  when  pressure  is  applied^  is  cut  through 
or  detached.  The  instrument  then  comes  in  contact  with 
the  hard  smooth  enamel,  and  unless  the  hand  is  so  guarded 
as  to  control  its  motions,  it  is  liable  to  slip  and  wound  some 
part  of  the  mouth,  especially  the  lower  lip.  Indeed^  this  is 
an  accident,  which,  unless  proper  precaution  is  observed, 
may  occur  in  filling  any  tooth. 

Among  the  principal  difficulties  which  the  dentist  en- 
counters in  filling  a  cavity  in  the  buccal  surface  of  a  lower 
molar,  apart  from  that  which  he  experiences  in  keeping  the 
cavity  dry  until  the  gold  is  introduced,  is  the  contact  of  the 
lower  and  inner  part  of  the  cheek  with  the  tooth.  But  this 
may  usually,  at  least,  to  a  considerable  extent,  be  pre- 
vented, and  the  commissure  of  the  lips  at  the  same  time 
pushed  back,  with  the  fore-finger  of  the  left  hand  of  the 
operator,  which  serves,  when  the  cavity  is  shallow  and  the 
orifice  large,  to  hold  the  gold  in  place,  until  a  sufficient 
quantity  is  introduced  to  obtain  mechanical  support  from 
the  surrounding  walls.  It  is  sometimes,  however,  attended 
with  much  difficulty,  but  in  operating  upon  the  bicuspids,  it 


334 


Fn,l.iNG   THE  INFERIOR   MOLARS   AND   BICUSPIDS. 


is  only  necessary  to  depress  the  corner  of  the  mouth  to 
obtain  free  access  to  the  cavity. 

Since  the  publication  of  the  sixth  edition  of  this  work, 
an  instrument  has  been  invented,*  for  the  purpose  of  keep- 
ing the  cheek  from  the  buccal  surface  of  the  lower  molars, 
depressing  the  tongue  and  holding  the  jaws  at  a  sufficient 
distance,  the  one  from  the  other.  One  portion  of  it,  as  may 
be  seen  from  the  engraving,  consists  of  two  guttered  plates, 
one  for  the  U2:)per  and  one  for  the  lower  molars,  connected 
by  a  screw,  working  in  a  vertical  cylinder — the  latter  cut 
on  the  inside  for  the  reception  of  the  spiral  bead  of  the 
former.  By  means  of  this  contrivance,  the  guttered  plates 
may  be  separated  or  brought  near  to  each  other,  according 
to  the  distance  it  may  be  desired  to  keep  the  jaws  apart. 
Around  the  connecting  portions   of  these  plates  are   two 

Fig.  106, 


rings,  each  about  three-eighths  of  an  inch  in  width.  From 
the  inside  of  the  lower,  a  shaft  a  little  more  than  three- 
fourths  of  an  inch  in  length  projects,  on  which  a  ring  is 
placed,  having  attached  to  its  lower  surface  a  tongue-holder, 
shaped  something  like  a  hand,  with  a  small  bar  at  the  ex- 
tremities of  the  fingers.  By  means  of  the  two  rings  be- 
longing to  this  part  of  the  instrument — the  one  sustaining, 
and  the  other  around  the  projecting  shaft,  the  tongue-holder 
may  be  adjusted  to  the  position  it  should  occupy,  and  made 

*  The  instrument  described  above,  was  invented  bj  Dr.  C.  C.  Thomas,  dentist, 
of  Bastrap,  La. 


FILLING  THE  INFERIOR  MOLARS   AND   BICUSPIDS.  335 

fast  by  tightening  the  screw  in  each  ring.  From  the  inside 
of  the  nj)per  large  ring,  a  square  bar  projects  and  passes 
into  an  extension  socket,  moved  by  a  ratchet  spring.  To 
the  extremity  of  this,  a  highly  polished  concave  oval  plate 
is  attached  by  a  ball  socket.  The  bar,  with  its  extension 
socket_,  may  be  lengthened  or  shortened,  at  pleasure — the 
concave  oval  j)late  at  the  extremity  holding  the  lower  part 
of  the  cheek  from  the  tooth  to  be  operated  on,  thus  fully 
exposing  the  cavity  in  its  buccal  surface,  and  reflecting  the 
light  directly  into  it. 

The  author  has  not  had  an  opportunity  of  testing  the 
practical  value  of  this  instrument,  but  he  is  inclined  to  be- 
lieve, having  seen  it  in  the  mouth,  that  it  may  be  advan- 
tageously used  in  some  operations,  especially  in  the  left 
lower  molars. 

For  the  introduction  of  the  gold  on  the  right  side,  either 
of  the  instruments,  represented  in  Figs.  84  and  94^  may  be 
employed,  but  on  the  left  side  the  latter  will,  as  a  general 
rule,  be  found  most  convenient.  A  straight  wedge-pointed 
instrument,  as  represented  in  Fig.  107^  can  often  be  advan- 
tageously used  in  introducing  the  foil  in  either  of  the  right 
bicuspids,    and  sometimes  even    in  the  Fia.  107. 

first  molar.  In  fact,  this  instrument 
can  often  be  used  efficiently  in  filling  a 
cavity  in  the  grinding  surface  of  a  molar  of  either  jaw,  but 
oftener  in  the  upper  than  the  lower.  It  is  scarcely  neces- 
sary to  say,  that  the  introduction  of  the  gold  should  proceed 
from  behind  forwards. 

Fig.  108. 


The  instruments  represented  in  Figs.  87  and  96,  may  be 
used  in  consolidating  the  extruding  portions  of  foil,  as  also 
the  one  rei)resented  in  Fig.  93. 

When  the  cavity  is  situated  near  the  gum^  or,  as  is  often 


336  FILLING   THE  INFERIOR   MOLARS   AND   BICUSPIDS. 

the  case,  when  the  lower  part  of  it  is  a  little  below  its  mar- 
gin^ the  precaution  of  removing  all  the  overlapping  por- 
tions, and  this  sometimes  constitutes  a  difficult  part  of  the 
operation,  ought  never  to  be  omitted.  For  this  purpose, 
the  file  represented  in  Fig.  108,  may  be  very  advantage- 
ously used.*  Some  are  made  straight  at  each  end,  others 
are  curved.  These  files  are  very  useful,  not  only  for  the 
purpose  just  stated,  but  also  for  filing  down  the  extrud- 
ing gold  of  a  filling  in  the  approximal  and  other  surfaces 
of  nearly  all  the  teeth. 

It  may  be  well  to  mention  here,  that  in  filling  a  molar  or 
bicuspid  on  the  left  side  in  the  uj)per  jaw,  whether  in  the 
grinding,  approximal  or  buccal  surface,  the  back  of  the 
chair,  if  so  constructed  as  to  admit  of  being  moved,  should 
be  thrown  five  or  six  inches  farther  back,  to  lower  the  head 
of  the  patient  and  give  the  face  a  more  horizontal  inclina- 
tion. By  this  means  the  operator  is  enabled  to  approach 
the  locality  of  his  manipulations  with  greater  ease,  thus 
enabling  him  to  exercise  a  more  perfect  control  over  his  in- 
strument, as  well  as  the  corner  of  the  mouth.  But  if  the 
back  of  his  operating  chair  is  stationary,  he  should  stand 
upon  a  stool  of  five  or  six  inches  in  height. 

The  foregoing  details,  with  regard  to  the  manner  of  fill- 
ing teeth,  will  serve  as  a  general  guide  for  the  performance 
of  the  operation,  and  at  the  same  time,  give  to  the  student 
and  inexperienced  practitioner,  some  idea  of  the  amount  of 
labor,  accuracy  of  manipulation,  and  perfection  of  execu- 
tion, it  requires. 

The  manner  of  building  on  the  whole  or  part  of  the  crown 
of  a  tooth,  will  be  described  in  a  subsequent  chapter. 


*  This  most  useful  and  valuable  instrument  was  invented  bj  Dr.  Elisba  Towns- 
end,  of  Philadelphia. 


CHAPTER     FIFTH. 

FILLING    TEETH   WHEN    THE   LINING    MEMBRANE   IS 

EXPOSED. 

The  propriety  of  filHng  a  tooth  after  the  invasion  of  the 
pulp  cavity  by  caries,  without  first  destroying  the  pulp,  is 
doubted  by  many  practitioners.  It  is  thought  that  inflam- 
mation and  suppuration  of  the  lining  membrane  and  pulp, 
must  as  a  necessary  consequence,  result  from  the  operation. 
But  Dr.  Koecker,  who  was  the  first  to  recommend  filling  a 
tooth  under  such  circumstances,  cites  a  number  of  cases  in 
which  he  performed  the  operation  successfully.  He  also 
expresses  the  belief  that,  "on  an  average,  five  out  of  six 
teeth  may  be  preserved  alive,  and  rendered  useful  for  a  long 
space  of  time,"  after  the  lining  membrane  has  become  ex- 
posed. The  author  has  been  in  the  constant  habit  of  filling 
teeth  under  such  circumstances,  whenever  a  favorable  case 
presented  itself,  since  1846,  and  occasionally  for  nearly 
twelve  years  previously  to  this  period,  and  his  experience 
warrants  the  belief,  that  the  vitality  of  a  much  larger  rela- 
tive proportion  may  be  saved  under  skillful  treatment.  He 
believes  he  has  been  successful  in  at  least  fourteen  cases  out 
of  every  fifteen,  since  1853^  and  it  may  be,  as  he  has  stated 
in  another  place,  that  when  the  treatment  of  teeth  in  which 
caries  has  penetrated  to  the  pulp-cavity  shall  be  better  under- 
stood, the  vitality  of  a  still  larger  relative  portion  may  bo  pre- 
served. At  any  rate,  so  long  as  it  can  be  done  in  even  nine 
cases  out  of  ten,  the  operation  must  be  regarded  as  valuable, 
for  a  healthy  living  tooth  is  less  liable  to  become  obnoxious 
to  the  surrounding  parts  than  one  deprived  of  a  large  por- 
tion of  its  vitality. 


338        FILLING  TEETH   OVER  EXPOSED   LINING  MEMBRANE. 

The  fact  that  teeth  can,  in  very  many  cases,  be  preserved 
alive  after  the  lining  membrane  has  become  exposed,  being 
admitted,  the  question  arises,  does  the  pulp  remain  in  the  con- 
dition in  which  it  is  at  the  time  the  operation  is  performed? 
It  is  difficult  to  conceive  how  a  vacant  space  can  exist  be- 
tween it  and  the  filling,  or  that  a  foreign  body  can  remain 
in  contact  with  it,  with  impunity.  Drs.  Harwood,  of  Bos- 
ton, and  J.  H.  Foster  and  W.  H.  Dwindle,  of  New  York, 
are  of  the  opinion,  from  experiments  they  have  made_,  that 
it  ossifies.  That  some  change  of  this  sort  does  take  place, 
is  well  known,  and  the  transition  is  evidently  the  result  of 
increased  vascular  action,  caused  by  irritation.  Examples 
of  this  kind  are  met  with  in  teeth  in  which  the  crowns  have 
lost  a  considerable  portion  of  their  substance  from  mechani- 
cal or  spontaneous  abrasion,  and  it  is  a  beautiful  provision 
of  nature  to  prevent  the  exposure  of  these  delicate  and 
highly  sensitive  parts.  The  same  thing  sometimes  occurs 
in  teeth  which  have  suffered  no  loss  of  substance,  and  in 
this  case,  it  is  doubtless  the  result  of  some  constitutional  or 
local  cause  of  irritation. 

These  facts,  as  we  have  elsewhere  stated,  would  seem  to 
justify  the  conclusion  that  the  pulp  of  a  tooth,  when  sub- 
jected, for  a  sufficient  length  of  time,  to  the  influence  of  an 
irritating  agent,  capable  of  exciting  only  a  very  slight  in- 
flammatory action,  undergoes  ossification ;  or  rather  is  con- 
verted into  a  substance  resembling  crusta  petrosa,  or  what 
Professor  Owen  terms  osteo -dentine.  When  it  fails  to 
undergo  this  change  in  a  tooth  which  has  been  filled  after 
the  lining  membrane  has  become  exposed,  it  is  liable^  from 
constitutional  disease,  or  other  causes,  either  to  perish  from 
derangement  of  its  nutritive  functions,  or  to  become  the 
seat  of  active  inflammation  and  to  suppurate.  But  some- 
thing more  than  mere  ossification,  or  its  conversion  into 
osteo-dentine,  takes  place  when  a  space  is  left  between  it  and 
the  filling.  If  this  vacant  space  was  not  obliterated,  we 
have  reason  to  believe  that  the  slightest  increase  of  vascular 
action  would,  as  has  been  justly  remarked  by  Dr.  Elliot, 


FILLING   TEETH   OVER    EXPOSED   LINING   MEMBRANE.         339 

force  a  portion  of  the  pulp  into  it,  and  thus  brought  in  con- 
tact with  the  sharp  angles  of  the  walls  of  the  cavity,  active 
inflammation  would  be  excited,  and  this,  as  a  natural  con- 
sequence, would  be  likely  to  terminate  in  suppuration. 
But  we  believe,  from  experiments  which  we  have  made, 
that  nature,  ever  fruitful  in  her  resources,  uses  means  for 
the  prevention  of  such  an  occurrence;  consisting,  first,  in 
filling  the  vacant  space  with  coaguldble  lymph,  (liquor 
sanguinis,)  effused  from  the  lining  membrane  or  exposed 
surface  of  the  pulp — then,  in  its  organization,  and,  lastly, 
its  conversion  into  callus  and  hone,  or  more  properly,  osteo- 
dentine.  Nature  seems  to  employ  the  same  means  here 
that  she  does  in  other  parts  of  the  body,  for  the  reparation 
of  injuries. 

When  this  reproductive  process  does  not  take  place  after 
the  operation,  it  may  be  owing  either  to  the  want  of  in- 
creased vascular  action  in  the  lining  membrane  or  pul23,  or, 
to  too  much  inflammation.  A  certain  amount  of  increased 
vascular  action  seems  necessary  to  the  effusion  of  coagulable 
lymph,  an  indispensable  requisite  to  it,  but  when  this  is 
too  great,  it  must,  of  necessity,  terminate  in  suppuration. 
This  being  the  case,  it  is  obvious  that  the  success  of  the 
operation  must  very  greatly  depend  upon  the  circumstances 
under  which  it  is  performed.  However  skillful  the  operator 
may  be  in  the  preparation  of  the  cavity  and  the  introduction 
of  the  gold,  if  these  be  unfavorable,  his  efforts  to  preserve 
the  vitality  of  the  organ,  will  in  a  large  majority  of  cases, 
prove  unavailing.  The  health  of  the  patient  should  be  un- 
impaired, the  tooth  of  a  tolerably  good  quality,  free  from 
pain  at  the  time  the  operation  is  performed,  it  should  never 
have  ached,  and  the  pulp,  peridental  membranes  and  sur- 
rounding parts  be  in  a  perfectly  healthy  condition.  The 
cavity,  too,  should  be  of  a  proper  shape  for  the  easy  intro- 
duction and  permanent  retention  of  the  filling,  and  the 
smaller  the  point  of  exposure  of  the  lining  membrane,  the 
greater  the  prospect  of  success.  It  is  also  important  that 
every  particle  of  completely  decomposed  dentine  be  removed 


340         FILLING   TEETH   OVER   EXPOSED   LINING   MEMBRANE. 

and  if  there  be  any  oozing  of  blood  from  the  ruptured 
vessels^  this  must  cease  before  the  filling  is  introduced. 

The  method  of  procedure,  pursued  by  Dr.  Koecker  in  the 
performance  of  the  operation,  is  as  follows  : 

First. — Eemove  the  caries  and  give  to  the  cavity  a  proper 
shape  for  the  reception  and  retention  of  the  filling;  then 
free  it  of  all  dust  that  may  be  in  contact  with  the  pulp,  with 
a  little  raw  cotton  moistened  in  warm  water. 

Second. — If  the  lining  membrane  is  not  wounded,  dry 
the  cavity,  and  place  a  small  plate  of  thin  leaf  lead  over  the 
exposed  nerve  and  surrounding  dentine ;  then  fill  the  cavity 
in  the  ordinary  way  with  gold. 

Third. — When  the  lining  membrane  is  wounded  and 
bleeds,  cauterize  the  part  with  an  iron  wire,  heated  to  a  red 
heat — using  the  precaution  not  to  wound  the  pulp.  After 
the  hemorrhage  has  been  arrested  and  an  artificial  cicatrix 
formed,  free  the  cavity  from  all  loose  extraneous  matter,  in 
the  manner  as  before  directed,  then  cover  the  nerve  with 
sheet  lead  and  fill  as  before  directed. 

The  reason  assis:ned  bv  Dr.  Koecker  for  coverino;  the 
nerve  with  lead,  is  that  it  has  a  ''more  cooling  and  anti- 
inflammatory effect"  than  gold.  He  also  states  that  when 
he  employed  gold  exclusively,  he  was  seldom  successful,  and 
that  inflammation,  pain,  etc.,  generally  supervened,  render- 
ing the  removal  of  the  filling  necessary. 

The  foregoing  method  of  treating  an  exposed  dental  pulp 
has  not  proved  so  successful  in  the  hands  of  other  practi- 
tioners. It  has  been  found  that  inflammation  and  suppura- 
tion sujiervene  in  a  large  majority  of  the  cases,  and  especi- 
ally, M'heu  the  cautery  is  used — consequently,  the  practice 
is  now  seldom  resorted  to.  The  direct  application  of  any 
metallic  substance  to  the  lining  membrane  or  pulp,  is,  ac- 
cording to  the  observations  of  the  author,  very  apt  to  be 
followed  by  inflammation  and  sujipuration  of  these  tissues . 
Some  of  the  vessels  of  "the  lining  membrane  are  always 
necessarily  wounded  in  removing  the  last  layer  of  decom- 
posed dentine,  but  the  hemorrhagCj  when  no  other  injury 


FILLING   TEETH   OVER  EXPOSED   LINING  MEMBRANE.         341 

is  inflicted,  is  very  slight,  and  sometimes  scarcely  percepti- 
ble, so  that  the  operation  of  filling  need  never  be  delayed 
more  tlian  from  three  to  ten  minutes.  The  application  of  a 
small  particle  of  raw  cotton  moistened  with  spirit  of  cam- 
phor will  immediately  arrest  it. 

Dr.  S.  S.  Fitch  proposes  to  cover  the  nerve  when  exposed, 
with  a  plate  of  gold,  previously  to  filling  the  cavity,  and 
this,  in  the  opinion  of  the  author,  is  preferable  to  the  di- 
rect application  of  a  piece  of  leaf  lead,  as  recommended  by 
Dr.  Koecker.  It  is  certainly  a  better  protection  to  the  nerve, 
and  if  it  be  so  fitted  to  the  cavity  that  its  edges  shall  rest  upon 
the  surrounding  dentine,  a  filling  may  afterwards  be  intro- 
duced without  injury  to  the  pulp.  Still,  in  very  many  cases 
the  application  of  a  covering  of  this  sort  is  objectionable.  It 
is  difficult  to  fit  it  with  sufficient  accuracy  to  prevent  the  lia- 
bility of  its  being  displaced  in  the  introduction  of  the  filling ; 
and  when  the  cavity  is  very  shallow  it  will  often  occupy  so 
much  room  as  to  render  it  impossible  to  fill  the  remainder  of 
it  in  a  substantial  manner,  yet  it  may  sometimes  be  very  ad- 
vantageously applied. 

The  plan  pursued  by  Dr.  J.  H.  Foster  of  New  York,  in 
filling  teeth  after  the  pulp  has  become  exposed  or  is  covered 
only  by  a  very  thin  layer  of  dentine,  is  as  follows  :  "If," 
says  he,  'Rafter  a  careful  removal  of  all  the  defective  portion, 
within  and  about  the  parietes  of  the  cavity,  the  thin  layer 
of  bone  which  lies  adjacent  to  the  lining  membrane,  lias  a 
moderate  degree  of  consistency,  yet  not  sufficient  to  protect 
the  dental  pulp  from  irritation  caused  by  the  pressure  of  ex- 
ternal agents,  it  has  been  my  practice  to  leave  it  there,  and 
fitting  a  gold  cap  over  it,  (with  great  caution  as  to  its  proper 
adjustment  as  a  protection,)  proceed  to  fill  the  tooth."  But 
this  method  of  procedure,  he  says,  was  not  as  successful  as  he 
could  have  desired,  depending,  in  a  great  degree,  as  he  sup- 
posed, upon  the  extent  to  which  the  thin  subjacent  layer  of 
dentine  had  been  involved  in  diseases,  and  the  liability  of 
the  pulp  to  be  affected  with  heat  and  cold. 

But  to  guard  against  the  irritation  and  inflammation  pro- 


342        FILLING   TEETH   OVER   EXPOSED   LINING  MEMBRANE. 

cluced  by  this,  he  fills  the  concave  surface  of  the  gold  cap 
with  ''Hill's  stopping,"  using  the  precaution  to  preserve 
the  concavity,  so  that  it  may  not  press  upon  the  part  it  is 
designed  to  protect.  This  treatment,  he  says,  has  proved 
successful  in  a  considerable  majority  of  the  cases.  "Believ- 
ing," says  Dr.  F.,  "that  many  failures  occurred  in  conse- 
quence of  tlie  comparatively  small  portion  of  newly  exposed 
bone  which  was  covered  and  protected  by  the  non-conduct- 
ing medium^  I  resolved  to  try  another  experiment.  Instead 
of  lining  the  gold  cap,  after  having  fitted  it  accurately  upon 
the  floor  of  the  cavity,  I  filled  the  whole  of  the  cavity  exter- 
nal to  it,  with  Dr.  Hill's  composition,  (which  in  its  chemi- 
cal properties  and  action  is  a  harmless  agent,)  allowing  this 
to  remain  for  five  or  six  months  as  a  temporary  stopping." 
By  this  plan  of  procedure,  Dr.  F.  says  he  has,  with  one 
or  two  exceptions,  been  successful  in  preserving  the  vitality 
of  the  teeth  during  the  past  year.  He  also  states  that  he 
has  occasionally  removed  these  fillings  after  the  lapse  of  two 
or  three  months,  and  finding  the  irritability  of  the  tooth, 
still  continued,  he  refilled  them  in  the  same  manner  and 
permitted  the  filling  to  remain  two  or  three  months  longer, 
when_,  on  again  removing  the  stoppings,  he  found  the  in- 
flammation diminished,  and  the  subjacent  layer  of  bone  al- 
most firm  enough  to  bear  the  pressure  of  a  gold  filling  ;  but 
he  still  uses  the  cap  underneath  tlie  gold^  as  before.  He 
believeSj  however,  tliat  if  Hill's  "stopping"  could  be  relied 
upon  for  preserving  the  walls  of  the  cavity  for  one  or  two 
years,  as  perfectly  as  it  does  for  a  few  months,  that  the  caps 
might  be  removed,  and  a  solid  gold  filling  introduced,  with 
out  danger  of  causing  irritation  by  pressure  upon  the  bot- 
tom of  the  cavity.*     Dr.  F,  further  adds,  that  he  has  fre- 

*  The  author  will  state  one  fact  here,  in  connection  with  what  Dr.  Foster  sajs  in 
relation  to  Hill's  "stopping."  Mr.  S.  of  Baltimore,  applied  to  the  author,  in 
Maj,  1848,  to  fill  the  first  left  superior  molar,  which  had  a  large  cavity  in  its  anterior 
approximal  surface.  On  examination,  it  was  found  that  the  pulp  had  been  destroyed, 
and  that  there  was  a  discharge  of  fetid  matter  from  the  pulp  cavity.  As  he  was 
anxious  to  retain  the  tooth,  the  decomposed  portions  were  removed,  to  the  extrem- 
ities of  the  roots,  and  the  cavities  injected,  once  a  day,  for  some  eight  or  ten  days, 


PILLING  TEETH   OVER   EXPOSED   LINING  MEMBRANE,        343 

quently  taken  out  gold  fillings  of  his  own  insertion,  ^^hj 
way  of  experiment,  which  had  heen  introduced  under  like 
circumstances,  after  they  had  been  in  for  two  or  more 
years,  and  on  removing  the  cap,  had  found  the  bone  beneath, 
so  unyielding  and  void  of  sensibility,  that  he  was  able  to 
introduce  a  solid  gold  filling  without  the  cap." 

The  method  pursued  by  the  author,  in  filling  a  tooth  af- 
ter caries  has  penetrated  to  the  pulp  cavity,  is  a  very  simple 
one.  The  caries  is  removed  and  the  cavity  prepared  in  the 
usual  manner,  using  the  precaution  not  to  wound  the  lining 
membrane  if  it  can  be  avoided,  though  some  of  its  vessels 
are  always  ruj^tured  in  the  removal  of  the  last  layers  of  de- 
composed dentine  ;  then,  to  wipe  out  the  cavity  very  care- 
fully with  a  dossil  of  raw  cotton,  saturated  with  spirit  of 
camphor,  which  immediately  arrests  the  efi'usion  of  blood 
from  the  minute  capillary  vessels.  The  gold  is  next  intro- 
duced, commencing  by  placing  the  folds  on  one  side  of  the 
cavity,  and  afterwards  inserting  fold  after  fold,  without  car- 
rying those  immediately  over  the  exposed  part  of  the  lining 
membrane  or  pulp,  to  the  bottom  of  the  cavity,  until  every 
part,  except  a  very  small  space  immediately  over  the  nerve^ 
is  thoroughly  filled.  The  folds  are  forced  so  tightly  one 
against  the  other,  as  to  prevent  the  liability  of  pressing 
their  inner  extremities  in  the  consolidation  of  the  extruding 
portions  of  the  filling  against  the  exposed  pulp  at  the  bot- 
tom of  the  cavity.  After  the  gold  has  been  thoroughly 
condensed,  the  surface  of  the  filling  is  finished  in  the  man- 
ner as  before  described. 

with  a  strong  solution  of  chloride  of  soda.  The  fetid  discharge  had  by  this  time 
apparently  ceased ;  but  still  fearing,  that  if  the  tooth  was  filled,  alveolar  ab- 
scess would  form,  the  author,  with  a  view  of  ascertaining  the  eflFect  which  would 
be  produced  by  the  operation,  filled  the  tooth  with  Ilill's  "stopping,"  request- 
ing Mr.  S.  to  call  on  him  again  in  three  weeks,  if  the  tooth  should  occasion  him  no 
pain,  or  sooner  if  it  should  become  troublesome.  This  he  promised  to  do,  but  as 
he  was  much  occupied  with  business,  he  neglected  to  keep  his  appointment.  As 
the  tooth  gave  him  no  uneasiness,  he  deferred  calling  from  week  to  week,  until 
nearly  two  years  had  elapsed.  Recollecting,  however,  that  his  tooth  had  only  a 
temporary  filling  in  it,  he,  on  the  25th  of  April,  1850,  called  to  have  it  filled  with 
gold.  To  the  astonishment  of  the  author,  the  walls  of  the  cavity  were  found  to  be 
in  as  sound  a  condition  as  when  the  "soft-stopping"  was  introduced. 


344       FILLING   TEETH   OVER  EXPOSED  LINING  MEMBRANE. 

The  author  has  occasionally  placed  a  drop  of  the  so- 
lution of  gutta  percha  in  the  bottom  of  the  cavity,  and 
waited  until  the  chloroform  had  completely  evaporated, 
before  introducing  the  gold.  He  has  also  used  collodion 
in  the  same  way.  Dr.  Elliot  of  Montreal,  states  in  an 
article  on  filling  teeth  over  exposed  nerves,*  that  he  places 
the  gold  ' 'directly  upon  the  living  nerve,  and  in  perfect 
contact  with  it,  over  the  whole  of  its  exposed  surface," 
using,  when  the  cavity  is  sufficiently  deep  to  admit  of  it, 
asbestos,  a  non-conductor,  ^^ enveloped  in  a  few  thicknesses  of 
gold  foil."  He  also  says,  that  within  the  last  year  he  had 
"but  two  cases  in  which  irritation  advanced  so  far  as  to  be- 
become  troublesome  to  the  patient,"  and  that  in  "both  in- 
stances, x^erfect  and  permanent  relief  was  obtained  by  the 
use  of  leeches  and  a  mild  cathartic."  We  are  inclined  to 
believe,  however,  that  by  leaving  a  vacant  space  between 
the  filling  and  the  pulp,  the  success  of  the  o^^eration  will  be 
rendered  more  certain. 

The  result  of  the  operation,  however,  performed  in  either 
way,  cannot  always  be  immediately  ascertained.  Though 
it  may  at  first  be  ajjparently  successful,  suppuration  of  the 
lining  membrane  and  pulp  may  take  place,  three,  six,  or 
even  twelve  months  after  the  introduction  of  the  filling. 

Dr.  S.  P.  Hullihen,  described  to  the  author  in  the  fall  of 
1851,  a  method  which  he  had  recently  introduced  of  treat- 
ing teeth  after  the  lining  membrane  had  become  exposed. 
It  consists,  after  filling  the  tooth  in  the  usual  way,  of  drill- 
ing a  hole  with  a  small  spear-pointed  drill,  about  a  line 
above  the  edge  of  the  alveolus  through  the  gum,  alveolar 
wall  and  root  into  the  j)ulp-cavity,  using  the  precaution  not 
to  separate  the  nerve,  and  wounding  it  as  slightly  as  possi- 
ble. The  efi'usion  of  lymph  resulting  from  the  inflamma- 
tion occasioned  by  the  pressure  of  the  filling,  escaj)es 
through  this  opening,  which,  he  believes,  when  the  in- 
creased vascular  action  subsides,  is  filled  with  callus,  and 
ultimately  with  dentine.     Dr.  H.  informed  the  author  he 

*  Am.  Jour.  Dent.  Sci.  No.  4,  vol.  1,  New  Series. 


FILLING   TEETH   OVER   EXPOSED   LINING  MEMBRANE.         345 

had  succeeded,  by  this  method  of  procedure,  in  almost  every 
instance  in  preserving  the  vitality  of  the  tooth.  The  au- 
thor has  not  jjerformed  the  operation  often  enough  to  enable 
him  to  express  an  opinion  with  regard  to  its  merits.* 

Without  going  into  detail,  we  have  now,  in  as  few  words 
as  2)ossible  given  all  the  information  we  possess  on  the  sub- 
ject of  filling  teeth,  with  a  view  to  the  preservation  of  their 
vitality,  after  the  lining  membrane  had  become  exposed; 
embracing  the  result  of  our  experience  since  the  publication 
of  the  fourth  edition  of  this  work,  which,  as  the  reader 
may  perceive,  has  very  greatly  increased  our  confidence  in 
the  utility  of  the  operation. 


*  Frcm  the  very  frequent  failures  of  the  operation,  it  is  now  very  seldom  if  ever 
performed. 


23 


CHAPTER     SIXTH. 

FILLING  PULP  CAVITIES  AND  ROOTS  OF  TEETH. 

This  operation  has  now  become  very  common.  It  is  prac- 
ticed, more  or  less,  by  many  dentists,  not  only  in  America, 
but  also  in  EurojDC,  altliougli  the  propriety  of  it  is  still 
doubted  by  many  practitioners.  The  objection  to  the  prac- 
tice is  founded  upon  the  supposition,  that,  in  proportion  as 
the  vitality  of  a  tooth  is  lessened,  it  becomes  obnoxious  to 
the  surrounding  living  parts. 

It  is  contended  that,  though  the  presence  of  the  tooth 
may  not  give  rise  to  alveolar  abscess,  it  is,  nevertheless,,  to 
some  extent,  a  local  irritant,  and  as  such,  must,  as  a  neces- 
sary consequence,  exert  a  morbid  influence^  not  only  upon 
the  living  parts  with  which  it  is  in  immediate  contact,  but, 
also,  upon  the  whole  economy.  Hence  it  is  argued,  that 
the  proper  remedial  indication,  after  the  death  of  the  lining 
membrane,  is  the  extraction  of  the  tooth,  and  this  reason- 
ing, it  must  be  admitted  by  all  who  have  any  knowledge  of 
the  laws  of  health  and  disease^  is  not  Avithout  much  seeming 
plausibility.  Until  comparatively  recently,  the  result  of 
most  of  the  efforts  made  for  the  preservation  and  retention 
of  teeth  in  this  condition,  fully  justified  its  supposed  cor- 
rectness ;  for,  in  nine  cases  out  of  ten,  the  operation  of  fill- 
ing, unless  an  opening  was  left  for  the  escape  of  the  matter 
secreted  at  the  extremities  of  the  roots^  was  followed,  sooner 
or  later,  by  alveolar  abscess.  The  conclusion,  therefore, 
that  such  teeth  could  not  remain  in  the  mouth  with  impu- 
nity, was  a  very  natural  one.  But  more  recent  experiments 
have  shown  it^  to  some  extent  at  least,  to  be  incorrect. 


FILLING  PULP-CAVITIES   AND   ROOTS   OF  TEETH.  347 

Drs.  Maynard  and  Baker  were  the  first  to  show  that  most 
of  the  morbid  phenomena  resulting  from  the  presence  of  a 
tooth  in  the  mouth  after  the  destruction  of  the  lining  mem- 
brane, were  caused  by  the  irritation  produced  by  the  matter 
contained  in  the  pulp-cavity  and  canal  of  the  root.  To 
prevent  their  occurrence,  therefore^  they  propose  filling  both 
in  such  a  manner  as  completely  to  exclude  every  thing  else. 
The  accumulation  of  matter  here  being  prevented,  its  secre- 
tion at  the  extremity  of  the  root,  as  has  been  shown  by  re- 
peated experiments,  will,  in  a  majority  of  cases,  either  cease 
altogether,  or  go  on  no  faster  than  it  is  carried  ofi"  by  the 
absorbents.  Thus  it  would  seem,  that  the  amount  of  living 
principle  a  tooth  derives  from  the  investing  membrane  is 
sufficient,  ordinarily,  to  prevent  it  from  exerting  any  mani- 
fest morbid  action  upon  the  surrounding  living  parts. 

Although  it  is  desirable  that  the  operation  should  be  per- 
formed before  any  diseased  action  has  been  set  up  at  the  ex- 
tremity of  the  root,  much  advantage  may  sometimes  be 
derived  from  it  even  after  alveolar  abscess  has  actually  oc- 
curred. Dr.  Maynard  informed  the  author,  that  he  had 
succeeded  in  curing  the  disease  by  it.  Other  dentists  have 
also  done  it,  and  the  author  has  certainly  known  great 
benefit,  in  several  instances,  to  result  from  cleansing  and 
filling  the  roots  of  teeth  which  had  given  rise  to  abscess. 
The  discharge  of  matter  has,  in  most  cases,  on  which  he  has 
operated,  been  greatly  diminished,  often  subsiding  alto- 
gether for  several  months  at  a  time,  and  the  recurrences 
rarely  'occasioning  much  inconvenience,  or  continued  for 
more  than  a  week,  or  ten  days.  Still,  he  does  not  feel 
warranted,  from  his  own  observations  and  experience,  in 
recommending  the  operation  in  cases  of  this  sort,  unless 
the  presence  of  the  tooth  is  called  for  by  some  peculiar  ne- 
cessity. 

During  the  year  1849,  Dr.  J.  H.  Foster  filled  the  pulp- 
cavities  and  roots  of  forty  teeth,  with  the  following  results: 


348  FILLING   PULr-CA"\T:TIES   AND   ROOTS   OF   TEETH. 


Alveolar  Abscess. 

Successful. 

Unsuccessful 

3  Superior  molars, 
1  Inferior  molar,  inflamma 
tion  without  abscess,  . 

1 
1 

3 
1 

9  Sui)erior  bicuspids,   . 
4  Inferior        do.           .      . 

1 

2 

8 
4 

1 

7  Superior  cuspidati,   . 
2  Inferior        do.           .      . 

1 

1 

1 
1 

1 

13  Superior  incisors,     .     . 
1  Inferior        do. 

1 

13 

1 

''In  the  case  of  the  superior  bicuspid,  marked  unsuccess- 
ful, Dr.  F.  says^  the  patient  would  not  submit  to  the  pain, 
and  insisted  upon  the  removal  of  the  tooth  during  the  inci- 
pient stage  of  alveolar  abscess.  In  that  of  the  superior 
cuspid,  the  abscess  did  not  form  until  some  months  after 
the  operation.  It  was  opened  in  due  time,"  but  as  the 
parts  still  continued  painful,  an  attempt  was  made  to  re- 
move the  filling.  This  was  unsuccessful,  and  as  the  pain 
continued,  the  tooth,  which  he  had  filled  into  the  root  from  a 
cavity  in  the  labial  surface,  was  extracted.  The  fang  was 
of  an  unusual  length,  and  had  a  bold  lateral  curvature 
about  three-fourths  of  the  way  up  to  the  apex,  rendering 
the  i)assage  of  an  instrument  beyond  the  angle  impossible. 
He  had,  however,  forced  the  first  piece  of  foil  a  little  below 
this  curve,  which  resisted  all  efforts  for  its  removal.  The 
fang  below  this  point  had  become  discolored  and  the  perios- 
teum inflamed. 

The  application  of  creosote  to  the  inner  walls  of  the  sac, 
introduced  through  the  canal  in  the  root,  previously  to  fill- 
ing, has  been  recommended  as  the  most  certain  means  of 
cure  that  has  ever  been  adopted.*  The  author  has  tried  it 
with  very  gratifying  results.  It  is  introduced  to  the  sac  at 
the  extremity  of  the  root  on  the  end  of  a  thread  of  waxed 
floss  silk,  through   the  pulp-cavity  and  canal  of  the  fang, 

*  The  treatmeut  of  alveolar  abscess  with  creosote  preparatory  to  filling  the  pulp- 
cavity,  was  first  recommended  bj  Dr.  C.  W.  Ballard. 


FILLING   PULP-CAVITIES   AND   ROOTS  OF   TEETH.  349 

previously  freed  of  all  extraneous  matter.  Another,  and  in 
some  respects  a  better  mode  of  applying  this  agent  to  the 
ulcerated  inner  surface  of  the  sac,  is  to  throw  it  into  the 
tooth  with  a  syringe,  the  opening  in  the  crown  being  first 
closed  with  a  piece  of  caoutchouc,  with  a  perforation  large 
enough  to  admit  the  tube  of  the  instrument.  The  creosote 
is  used  in  the  form  of  a  strong  alcoholic  solution,  say  one 
drachm  of  creosote  to  an  ounce  of  alcohol.  This  being  for- 
cibly injected  into  the  tooth,  passes  through  the  sac  at  the 
end  of  the  root  and  escapes  through  the  fistulous  opening  in 
the  gum,  where  it  is  caught  in  a  piece  of  soft  moist  sponge 
or  a  few  folds  of  bibulous  paper.*  There  are  many  cases, 
however,  in  which  there  is  a  slight  morbid  secretion  that 
escapes  through  the  tooth  without  any  discharge  from  the 
gums.  The  most  efiicacious  means  of  arresting  this  are  the 
same  as  those  recommended  for  the  treatment  of  abscess  of 
the  socket.  But  the  creosote  in  this  case  should  be  intro- 
duced in  the  manner  as  first  described. 

A  professional  friendf  states,  in  a  letter  to  the  author, 
dated  March  12th,  1850^  that  he  has  been  for  several  years, 
and  is  now  constantly  in  the  habit  of  filling  teeth  and  their 
fangs,  after  destroying  their  nerves,  and  also  of  cleansing 
and  filling  the  cavities  of  the  fangs  of  teeth  which  had  pre- 
viously lost  tiieir  vitality^ |  and  had  become  more  or  less 
diseased.  He  also  states,  that  but  very  few  cases  had  oc- 
curred in  his  practice,  where  ulceration  had  occurred,  ren- 
dering the  removal  of  the  tooth  necessary.  He  furthermore 
remarks,  that  whenever  the  investing  membrane  and  gums 
of  teeth,  treated  in  this  manner,  become  thickened  and 
swollen,  the  symptoms  are  less  severe.  In  proof  of  the  cor- 
rectness of  this  opinion,  he  has  furnished  the  author  with 

*  This  method  of  applying  remedial  agents  to  the  inner  walls  of  the  sac  of  an 
alveolar  abscess,  is  recommended  by  Dr.  F.  H.  Badger. 

■)•  Dr.  E.  J.  Dunning,  of  New  York. 

I  By  the  loss  of  vitality,  we  presume  the  writer  means,  that  which  the  teeth 
derive  from  the  lining  membrane,  for  after  the  death  of  the  investing  periosteal 
tissue,  a  tooth  becomes  a  foreign  body,  and  must  of  necessity,  be  a  constant  source 
of  irritation. 


350  FILLING  PULP-CAVITIES  AND   ROOTS  OF   TEETH. 

the  following  details  of  a  case  whicli  came  under  his  obser- 
vation a  few  months  since. 

"A  gentleman  from  the  south  called  immediately  after 
his  arrival  in  this  city,  and  stated  that  during  his  passage 
in  the  steamer,  he  had  been  suffering  intensely  from  pain 
in  a  first  superior  molar.  On  examination  I  found  the 
tooth  thoroughly  injected  with  red  blood — the  periosteum 
highly  inflamed  and  considerably  thickened,  though  there 
was  no  swelling  of  the  gum.  A  small  cavity  in  the  poste- 
rior approximal  surface  had  been  filled  with  gold  a  day  or 
two  before  sailing.  In  preparing  the  cavity  for  filling, 
arsenic  had  been  used  to  allay  sensibility. 

'■'In  most  cases  I  should  have  advised  the  removal  of  the 
tooth_,  for  the  symptoms  were  most  unfavorable  to  any  ope- 
ration for  its  preservation.  But  as  the  mouth  was  otherwise 
perfectly  healthy,  the  arches  unbroken,  and  the  cavity  in 
the  tooth  very  small,  and  the  patient  extremely  anxious  to 
preserve  it,  I  determined  to  try  to  save  it. 

''On  examining  the  cavity  carefully,  I  found  that  the 
nerve  had  never  been  exj^osed — the  arsenic  had  acted  upon 
it  through  the  circulation,  and  had  thus  produced  this  severe 
inflammation. 

"Having  removed  the  layer  of  sound  bone  that  covered 
the  nerve,  and  finding  it  quite  sensitive^  I  made  an  applica- 
tion of  an  exceedingly  small  quantity  of  a  mixture  of 
arsenic,  morphine  and  creosote,  and  cov^ered  it  with  a 
metallic  cap  or  arch,  to  prevent  pressure,  followed  by  a 
loose  filling  of  tin  foil.  The  pain  and  much  of  the  soreness 
were  immediately  relieved. 

''Saw  the  patient  again  on  the  fourth  day — found  the 
soreness  entirely  gone — had  suffered  pain  since  the  applica- 
tion was  made — injection  remained  the  same.  Found  the 
part  of  the  pulp  contained  in  the  central  cavity  entirely 
insensible — removed  it ;  finding  the  portion  in  tlie  fangs 
still  sensitive,  made  the  same  application  at  the  entrance  of 
each  canal  and  filled  the  cavity  again  with  tin.  At  this 
sitting,  ventured  to  file  the  tooth  so  as  to  increase  the  sepa^ 


FILLING   PULP-CAVITIES   AND   ROOTS   OF   TEETH.  351 

ration  between  it  and  the  second  molar.  The  filed  surface 
showed  the  injection  beautifully,  the  bone  appearing  a 
bright  red,  and  the  line  at  the  junction  with  the  enamel 
very  distinct. 

"In  three  or  four  days  saw  the  patient  again,  and  to  my 
surprise  and  delight  found  that  the  injection  had  entirely 
disappeared,  and  the  tooth  almost  as  perfect  in  color  as  any 
of  its  neighbors.* 

"The  nerves  were  then  removed  from  the  fangs,  and  their 
places  filled  with  gold,  and  at  a  subsequent  sitting,  the  ex- 
ternal cavity  was  filled. 

"As  three  months  have  elapsed  since  the  operation  was 
performed,  without  any  news  with  regard  to  it^  I  conclude 
that  it  is  thus  far  successful." 

Other  cases  of  a  similar  character,  and  with  similar  re- 
sults might  be  given,  but  we  will  not  enlarge  further  upon 
this  part  of  our  subject. 

With  regard  to  the  best  means  for  destroying  the  nerve, 
or  rather  the  pulp  of  a  tooth,  there  exists  much  diversity  of 
opinion.  Immediate  extirpation  with  an  instrument,  arsenic 
and  the  actual  cautery,  are  the  ones  most  frequently  em- 
ployed, and  each  has  its  advocates. 

To  the  use  of  arsenic  and  all  similar  agents.  Dr.  Har- 
wood,  of  Boston,  is  strongly  opposed.  He  states,  in  a  letter 
to  the  author,  dated  February  13th,  1850,  that  "they  cause 
death  and  sloughing  in  the  parts  to  which  they  are  more 
immediately  applied,  and  irritation  and  unmanageable 
trouble  in  the    parts  next   beyond    those  they    absolutely 

*  The  injection  of  the  tooth  from  the  vessels  of  the  lining  luetubrane  and  pulp,  is 
of  frequent  occurrence  in  teeth  to  which  arsenic  is  applied  for  the  purpose  of 
merely  destroying  the  sensibility  of  the  dentine.  At  the  first  meeting  of  the  Amer- 
ican Society  of  Dental  Surgeons,  Dr.  Hayden  mentioned  a  case  that  had  a  short 
time  before  fallen  under  his  observation,  and  several  others  were  cited  by  the 
author  at  the  same  time.  Since  then  be  has  met  with  numerous  cases  in  which  this 
had  occurred.  It  is  doubtless  the  result  of  increased  vascular  action,  excited  in 
the  lining  membrane  and  pulp  by  the  action  of  the  arsenic,  and  it  proves  the  capa- 
bility of  the  vessels  of  teeth  under  certain  circumstances,  of  convrying  red  blood. 
It  occurs,  however,  much  more  frequently  in  the  teeth  of  young,  tlian  in  those  of 
persons  in  advanced  life. 


352  FILLING   PULP-CAVITIES   AND   ROOTS   OF  TEETH. 

kill.  In  other  words_,  they  irritate  the  parts  beyond  the 
dental  cavity,  and  from  this  cause,  (and  perhaps  from  chem- 
ical injury  to  the  tooth  itself,)  the  periosteum  of  the  root 
and  socket  becomes  the  seat  of  great,  and  frequently  of  un- 
controllable difficulty.  Entertaining  these  views.  Dr.  H. 
regards  the  use  of  such  means,  as  opposed  both  to  experience 
and  sound  philosophy,  and  adopts,  without  knowing  that 
the  same  thing  had  been  done  by  others,  what  he  believes 
to  be  a  more  correct  practice — immediate  extirpation.  He 
thus  describes  his  method  of  procedure  for  the  accomplish- 
ment of  this  object. 

He  says,  "I  first  effect  such  an  opening  as  will  enable  me 
to  approach  the  exposed  pulp,  in  the  line  of  its  axis,  or  as 
nearly  so  as  circumstances  will  permit.  Then,  having  care- 
fully but  sufficiently  exposed  the  surface  of  the  pulp,  I  pass 
down  to  the  apex  of  tlie  root,  through  the  pulp,  a  small  un- 
tempered  steel  instrument,  with  a  trochar-shaped  point,  and 
revolving  it  once  or  twice,  sever  the  vessel  and  nerve.  This 
as  any  one  knows,  who  is  accustomed  to  inserting  artificial 
teeth,  produces  but  a  slight  and  momentary  pain.  I  then, 
by  means  of  minute  instruments,  adapted  to  the  j)urpose, 
endeavor  to  remove  every  portion  of  the  severed  pulp  and 
lining  membrane,  and  as  soon  as  the  hemorrhage  ceases, 
dry  the  cavity  and  fill"  the  tooth. 

In  relation  to  the  subsequent  parts  of  the  operation.  Dr. 
H.  says,  "I  have  sometimes  only  filled  the  canals  at  the 
first  sitting — leaving  the  body  of  the  tooth  to  be  treated 
after  a  few  days.  This  course  has  been  adoj)ted  from  a  fear 
that  all  the  pressure  necessary  to  complete  the  oi:)eration, 
might  enhance  the  danger  of  inflammation  and  suppuration. 
This  is  prudent,  but  experieuce  does  not  convince  me  that  it 
is  necessary. 

''It  should  be  borne  in  mind_,  that  at  the  point  where  the 
vessels  and  nerve  in  question  enter  the  root,  the  passage  is 
much  smaller  than  it  is  immediately  within.  This  strait 
will  be  easily  recognized  when  reached,  by  the  touch,  the 
instrument  appearing  to  be  arrested  by  an  obstacle,  and  not 


FILLING  PULP-CAVITIES  AND   ROOTS   OF   TEETH.  353 

by  being  "wedged  in  a  narrow  passage.  Care  should  be 
taken,  I  think,  that  the  instrument  is  not  allowed  to  pass 
through  the  strait,  either  by  being  too  small,  or  by  being 
revolved  there  till  it  cuts  its  way  through.  For,  by  wound- 
ing the  parts  without  the  tooth,  and  forcing  particles  of 
bone  out  upon  the  parts  external  to  the  root,  the  danger  of 
an  unfavorable  result  would  be  greatly  increased." 

Dr.  Harwood  adds,  in  conclusion,  that  he  believes  it  is 
better  to  make  the  division  of  the  parts  a  little  within  the 
strait,  though  he  does  not  regard  the  matter  as  being  yet 
fully  settled  by  observation  and  experience. 

As  to  the  success  of  the  practice,  Dr.  H.  speaks  very  con- 
fidently, not  having  had  a  case  treated  in  this  manner, 
where  the  patient  and  pulp  were  healthy,  in  which  there 
has  been  a  single  s3anptom  of  alveolar  abscess. 

In  a  paper  read  before  the  American  Society  of  Dental 
Surgeons,  at  the  meeting  held  in  the  city  of  New  York, 
August,  1845,  and  published  in  the  sixth  volume  of  the 
American  Journal  of  Dental  Science,  p.  15,  Dr.  B.  J.  Dun- 
ning maintains  very  similar  views  with  regard  to  the  means 
most  proper  to  be  employed  for  the  destruction  of  the  pulp 
of  a  tooth.     He  says, 

"The  destruction  of  the  nerve  by  mechanical  means  has 
been  practiced  to  a  small  extent  by  dental  surgeons  for 
many  years,  but  on  account  of  the  severe  pain  which  in 
many  cases  attends  it,  as  well  as  the  fact  that,  in  the  man- 
ner in  which  it  has  generally  been  practiced,  it  has  proved 
no  more  successful  than  other  and  less  severe  methods, 
it  has  been  considered  rather  in  the  light  of  a  dernier 
resort,"  But  this.  Dr.  D.  believes  to  be  owing  to  the  fact, 
that  the  nerve  is  often  only  punctured  and  lacerated,  and 
afterwards  shut  up  in  the  tooth  and  left  to  decompose.  To 
prevent  which,  he  says,  the  whole  nerve  should  be  removed, 
and  its  place  filled  with  gold  or  tin  foil. 

Again,  Dr.  D.  says,  ''The  instrument  which  I  have  used 
to  excavate  the  fangs,  is  a  delicate  probe  of  steel,  perfectly 
annealed,     The  point  may  be  converted  iiito  g,  very  slight 


354  FILLING   PULP-CAVITIES   AND  ROOTS   OF   TEETH. 

hook,  and  made  sharp,  so  as  to  bring  away  the  nerve  or 
other  matter  with  which  the  cavity  may  he  filled.  For  the 
removal  of  the  nerve  in  the  chamber  of  the  crown,  exist- 
ing in  molar  teeth,  as  well  as  to  enlarge  the  cavity,  so 
as  to  give  free  access  to  each  of  the  fangs,  a  burr-drill  is 
very  useful.  As  these  teeth  are  generally  very  much  de- 
cayed, it  will  be  found  advisable,  when  the  cavity  is  on  the 
side  of  the  crown,  to  remove  its  edges  in  such  a  manner 
as  to  admit  the  light  directly  upon  the  openings  of  the 
fangs.  This  will  facilitate  the  operation  very  much,  and  at 
the  same  time  give  strens-th  to  the  walls  that  are  to  contain 
the  stopping." 

With  regard  to  the  result  of  the  operation  of  filling  the 
pulp-cavity  and  roots  of  a  tooth  in  which  the  nerve  has  been 
destroyed  in  the  manner  as  above  described.  Dr.  Dunning 
says,  so  far  as  he  has  been  able  to  observe,  it  has  been  suc- 
cessful in  every  case. 

On  the  different  methods  of  destroying  the  nerve.  Dr.  J. 
H.  Foster,  of  New  York,  says,  ''It  is  a  difficult  matter,  and 
I  have  generally  found  it  utterly  futile  to  attempt  to  induce 
patients  to  submit  to  the  removal  of  the  pulp  by  extraction 
or  excision  with  instruments,  in  those  cases  in  which  it  be- 
comes necessary  to  destroy  vitality  before  the  teeth  can  be 
filled. 

"To  obtain  the  consent  of  the  patient  by  a  representation 
of  the  advantages  of  this  mode  of  treatment,  as  contrasted 
with  the  more  slow  and  uncertain  practice,  in  its  immediate 
efiects,  of  extirpation,  by  the  aid  of  chemical  agents,  has 
been  my  earnest  endeavor.  I  do  not  remember  a  single 
case  of  the  removal  of  the  dental  pulp  by  an  instrument — 
the  gold  being  inserted  into  the  dental  cavity  immediately 
after  the  hemorrhage  has  been  checked — which  has  resulted 
in  alveolar  abscess." 

Dr.  Foster,  however,  generally  employs  arsenious  acid, 
with  sulph.  morphia,  in  the  proportion  of  two  grains  of  the 
former  to  eight  of  the  latter,  applied  on  a  small  pellet 
moistened  with  creosote.     After  applying  this  directly  over 


FILLING   PULP-CAVITIES   AND   ROOTS   OE   TEETH.  355 

the  nerve,  he  covers  it  with  a  cap,  to  avoid  pressure  ;  then 
fills  the  external  cavity  with. some  soft  material  which  will 
exclude  moisture.  At  the  end  of  forty-eight  hours,  he  re- 
moves this^  enlarges  the  dental  cavity,  removing  its  con- 
tents to  the  apex  of  the  root ;  then,  after  waiting  another 
forty-eight  hours,  he  proceeds  to  fill  the  canal,  leaving  the 
cavity  in  the  crown  to  he  filled  at  a  subsequent  sitting. 

In  performing  this  operation  on  molar  teeth,  "where 
there  is  a  probable  chance  of  a  favorable  issue,"  and  the 
preservation  of  these  teeth  is  particularly  called  for,  he 
thinks  it  important  that  the  excavation  should  be  done  at 
intervals,  so  as  to  cause  as  little  irritation  at  each  sitting  as 
possible,  and  that  the  filling  of  the  different  cavities  in  the 
tooth  be  also  proceeded  with  in  like  manner. 

Dr.  Maynard,  who  has  been  as  successful  in  filling  the 
pulp-cavity  and  roots  of  teeth  as  any  other  practitioner,  and 
has  probably  had  more  experience,  having  been  in  the  habit 
of  performing  the  operation  since  1838,  having  thoroughly 
tested  the  method  of  destroying  the  nerve  by  immediate  ex- 
tirpation with  an  instrument,  as  well  as  that  by  the  appli- 
cation of  arsenious  acid,  gives  the  preference  to  the  latter. 
His  method  of  procedure,  as  described  in  vol.  7,  p.  286,  of 
the  American  Journal  of  Dental  Science,  is  as  follows:* 
"He  takes  white  wax  and  works  it  into  cotton  or  lint,  till  it 
is  thoroughly  mixed  together.  With  this  he  fills  the  cavi- 
ty in  the  tooth."  But,  "before  doing  this,  he  exposes  the 
nerve  as  much  as  possible,  applies  the  arsenic,  and  caps  the 
orifice  with  a  plate  of  lead,  of  a  cup  shape,  the  convex  side 
outwards.  While  this  is  carefully  kept  in  place,  he  fills 
the  cavity  with  the  cotton  and  wax,  very  carefully  and  per- 
fectly, in  such  a  way  as  not  to  shut  in  and  compress  any  air 
which  might  press  upon  the  nerve.  On  removing  this 
packing,"  in  a  case  which  the  writer  had  an  opportunity  of 
witnessing,  he  says,  "I  was  surprised  to  see  that  liis  prepa- 
ration had  been  kept  perfectly  dry,  although  it  had  been 
there  twenty-four  hours. 

*  This  is  taken  from  an  article  by  Dr.  A.  Westcott. 


356  PILLING   PULP-CAVITIES   AND   ROOTS   OF   TEETH. 

''After  he  removed  this  packing  and  the  preparation,  he 
proceeded  to  remove  the  nerve..  Instead  of  attempting  to  do 
this  at  once,  he  began  by  cutting  on  every  side  of  the  orifice^ 
so  much  enlarging  it  as  to  be  enabled  to  remove  the  nerve 
without  pressing  the  contents  of  the  cavity  upwards. 

"It  was  to  us  a  matter  of  interest  to  examine  the  instru- 
ments used,  particularly  for  removing  the  nerve. 

''Some  of  his  probes  were  made  from  the  main-spring  of  a 
watch,  by  filing  or  grinding  them  sufficiently  narrow,  to 
enter  the  smallest  space  which  he  wished  to  probe.  In  this 
way  he  secures  the  most  perfect  spring  temper,  a  point  not 
easily  attained  in  so  frail  an  instrument  as  a  probe  adapted 
to  this  purpose.  These  probes  were  bearded  by  cutting 
them  with  a  sharp  knife — the  beards  pointing  backwards. 
"With  different  sizes  of  these  [and  other]  probes,  and  by 
enlarging  the  cavity  from  time  to  time,  he  removes  the 
nerve  to  the  extremity  of  the  root. 

The  author  of  a  series  of  ably  written  articles  on  the  treat- 
ment of  caries  of  the  teeth,  complicated  with  disorders  of  the 
pulp  and  peridental  membrane,*  published  in  the  American 
Journal  of  Dental  Science,  recommends  the  use  of  cobalt  for 
destroying  the  nerve  as  preferable  to  any  other  agent  or 
means  that  have  been  employed  for  the  purpose. 

In  the  destruction  of  the  pulp  of  a  tooth  the  author  has 
employed  both  mechanical  and  chemical  agents.  He  has 
been  in  the  habit  of  occasionally  extirpating  the  nervous 
pulp  to  the  extremity  of  the  root  by  introducing  a  very 
small  untempered  instrument,  with  a  spear-shaped  point, 
for  more  than  twenty  years,  though  not  at  first  with  the 
view  of  afterwards  filling  the  pulp  cavity.  He  has  also  used 
the  actual  cautery  and  arsenioua  acid,  To  the  use  of  the 
last  named  argent  as  used  by  most  dentists  for  destroying 
the  vitality  of  toeth^  he  was  at  one  time  strongly  opposed, 
and  he  still  believes  a  vast  amount  of  injury  is  produced 
by  it,  but  with  proper  caro  and  judicious  treatment  after 

?  Pr,  R.  ArtbuF, 


FILLING   PULP-CAVITIES   AND   BOOTS   OF   TEETH.  357 

the  destruction  of  the  pulp,  it  may  be  used  with  safety,  and, 
in  most  cases,  advantage.  It  is  the  agent  he  now  employs 
for  destroying  the  vitality  of  the  lining  membrane  and 
pulps  of  the  molar  and  bicuspid  teeth,  and  occasionally, 
he  applies  it  to  the  incisors  and  cuspids.  As  a  general 
rule,  however,  when  he  wishes  to  destroy  the  nerve  of 
one  of  the  last  named  teeth,  he  extirpates  it  by  thrusting  a 
small  instrument  up  the  pulp-cavity  to  the  extremity  of  the 
root.  When  he  uses  arsenic,  he  applies  about  the  thirtieth 
or  fortieth  part  of  a  grain,  Avith  an  equal  quantity  of  sul- 
phate of  morphia,  on  a  small  particle  of  raw  cotton,  moist- 
ened with  creosote^  or  spirit  of  camphor,  sealing  up  the  cav- 
ity with  white  or  yellow  wax.  At  the  expiration  of  seven 
or  eight  hours,  he  removes  the  wax  and  arsenic,  and  after- 
wards the  pulp  of  the  tooth.  If  the  portions  in  the  roots 
are  still  sensitive,  he  applies  it  a  second  time,  but  he  seldom 
finds  it  necessary  to  do  so. 

The  method  of  procedure  which  he  adopts  in  filling  the 
root,  or  roots  if  it  be  a  molar  tooth,  is  the  same  as  that  pur- 
sued by  Dr.  Maynard,  which  has  already  been  described. 

''His  operation,"  says  the  writer  just  quoted,  "of  filling 
the  root,  is  characterized  by  the  same  neatness  and  dexteri- 
ty. His  instruments  are  of  the  most  delicate  kind,  and  are 
adapted  to  reach  to  the  end  of  the  fang,  although  the  canal 
may  not  be  entirely  straight.  In  filling  these  roots,"  allud- 
ing to  the  operation  which  he  says  Dr.  M.  performed,  he 
used  very  heavy  gold,  we  believe  from  No.  12  to  30.  This 
is  cut  into  strips  corresponding  to  the  diameter  of  tlie  cavity, 
and  is  not  doubled.  The  end  of  one  of  the  strips  is  laid 
upon  the  end  of  one  of  these  delicate  pluggers,  and  carefully 
carried  up  to  the  ujDper  extremity  of  the  root.  If  this  is  ef- 
fected, the  instrument  is  withdrawn  a  slight  distance,  then 
returned,  carrying  with  it  another  portion,  till  the  strip  is 
exhausted.     In  this  way  the  whole  root  is  filled. 

This  part  of  the  operation  being  completed,  the  cavity  in 
the  crown  is  filled  in  the  usual  manner. 

It  sometimes  happens  that  the  canals  in  the  buccal  roots 


358  FILLING   PULP-CAVITIES   AND   ROOTS   OF   TEETH. 

of  the  upper  molars  are  so  small  as  to  preclude  the  introduc- 
tion even  of  a  small  sized  hog's  bristle.  In  cases  of  this 
sort,  it  is  impossible  to  fill  them,  and  fortunately,  from  their 
small  size,  they  cannot  serve  as  reservoirs,  for  accumula- 
tions of  morbid  matter.  The  canal  in  the  palatine  fansj  is 
always  much  larger  than  in  either  of  the  buccal  roots,  and 
a  majority  of  the  cases  is  filled  with  comparative  ease. 

We  have  now  presented  a  condensed  summary  of  most  of 
the  information  we  possess  in  relation  to  the  operation  on 
which  we  are  now  treating  ;  and  notwithstanding  the  favor- 
able light  in  which  it  is  viewed  by  many  eminent  dentists, 
we  think  it  should  be  restricted  to  teeth,  the  presence  of 
which  in  the  mouth,  is  called  for  by  some  peculiar  or  urgent 
necessity.  It  is  only  in  such  cases,  that  we  conceive  the  op- 
eration to  be  advisable ;  for  the  unsuccessful  results  which 
have,  at  least  occasionally,  attended  it,  in  the  practice  of 
every  one,  who  has  performed  it  many  times,  prove 
that  a  tooth,  after  the  destruction  of  even  the  lining  mem- 
brane and  pulp,  is  more  liable  to  give  rise  to  a  diseased  ac- 
tion in  the  socket,  than  a  tooth  not  deprived  of  these  essen- 
tial constituents.  If  these  parts  did  not  perform  some  ne- 
cessary function,  or  contribute  in  some  way  to  the  well  being 
of  the  tooth,  or  the  parts  with  which  it  is  connected,  they 
would  not  be  left  there ;  the  process  of  dentinification  would 
doubtless  be  carried  on  until  the  cavity  in  which  they  are 
contained  was  completely  obliterated.  Still,  these  parts,  as 
we  have  already  stated,  and  as  is  fully  proved  by  the  facts 
which  have  been  adduced,  may  often  be  dispensed  with 
without  causing  a  tooth  to  exercise  any  immediate  manifest 
hurtful  action  upon  the  surrounding  parts  or  general  system. 

It  sometimes  happens  tliat  the  crown  of  a  tooth,  in  Avliich 
the  central  cavity  has  been  filled  for  a  length  of  time  with 
black  purulent  matter,  or  the  pulp  after  having  been  acci- 
dentally deprived  of  vitality  by  the  application  of  arsenic  to 
a  carious  cavity,  with  a  view  of  merely  destroying  sensibility, 
assume  a  dark  brown,  and  sometimes  almost  a  black  color. 
This,  in  some  cases,  extends  to  every  part  of  the  dentine  of 


FILLING   PULP-CAVITIES   AND   ROOTS   OF   TEETH.  359 

,the  crown,  and  in  such  cases  it  is  important  to  restore  tlie 
/  natural  color  of  the  organ,  before  filling.     The  agent  which 
■  the  author  has  employed  for  this  purpose,  for  a  number  of 
years,  is  a  solution  of  the  chloride  of  soda.     After  freeing 
the  pulp-cavity  to   the  extremity  of  the  root  of  all  impuri- 
ties, and  removing  from  its  inner  walls,  the  softened  or  de- 
composed portions  of  dentine,  he  fills  the  tooth  with    raw 
/  cotton,  saturated  with  this  solution,  closing  the  orifice  with 
I  white  wax,  and  permitting  the  whole  to  remain  for  twenty- 
four  hours.     A  single  application  will  sometimes  produce 
the  desired  efiect ;  at  other  times  several  are  necessary.     Dr. 
Dwindle  has  used  successfully,  for  the  same  purpose,  a  so- 
lution of  lime. 


CHAPTER    SEVENTH. 

FILLING  TEETH  WITH  CRYSTALLIM  AND  SPONGE  GOLD. 

Two  preparations  of  gold  for  filling  teeth,  each  differing 
somewhat  in  appearance,  and  to  some  extent  in  properties, 
from  the  other,  and  both  from  foil  or  leaf  gold,  have  within 
the  last  few  years  been  brought  to  the  notice  of  the  dental 
profession.  Each  has  a  spongy  texture  and  appearance, 
but  one  is  composed  of  crystals,  and  the  other  of  small 
granular  particles.  The  former  is  reduced  more  readily,  by 
pressure_,  into  a  solid  mass,  than  the  latter,  and  hence  has 
been  found  better  adapted  to  the  operation  of  filling  teeth. 
But  in  the  use  of  either  of  these  preparations,  a  different 
method  of  procedure  is  required  from  that  employed  with 
foil ;  and  the  instruments  necessary  to  make  a  filling  with 
the  one^  are,  in  many  cases,  unsuited  to  the  operation  with 
the  other.  A  separate  description  of  the  system  of  manip- 
ulation, therefore,  is  deemed  necessary. 

INSTRUMENTS  EMPLOYED  IN  THE  OPERATION. 

The  chief  difference  between  the  instruments  employed 
for  introducing  these  preparations  of  gold  into  the  cavity  of 
a  tooth,  and  consolidating  them,  from  those  used  for  foil, 
consists  mainly  in  having  the  working  extremity  blunt,  but 
varying  in  diameter  from  a  line  down  to  nearly  a  sharp 
point,  with  cross  cuts  upon  the  surface,  giving  it  a  sharp 
denticulated  appearance.  Some  original  forms  of  instru- 
ments have,  however,  been  invented,  but  most  of  those  used 


INSTRUMENTS   EMPLOYED   IN    FILLING  TEETH. 


361 


Fia.  109. 


Fig.  110. 


at  present  are  mere  modifications  of  instruments  heretofore 
employed  for  filling  teeth  with  gold-foil.* 

In  Fig.  109  is  seen  a  representation  of  an  instrument 
with  a  round  point,  flat  on  one  side  and  slightly 
convex  on  the  other,  designed,  chiefly,  for  carry- 
ing small  masses  of  crystalline  or  sponge  gold  to, 
and  pressing  them  in,  the  orifice  of  the  cavity  of 
the  tooth  to  he  filled,,  or  to  place  them  u^jon  that 
previously  introduced.  It  is  a  convenient  and 
useful  instrument,  and  cannot  well  be  dispensed 
with  in  working  these  preparations  of  gold. 
Several  sizes  are  required. f 

An  instrument  somewhat  similar 
to  the  foregoing  is  represented  in 
Fig.  110.  The  point,  instead  of 
being  round  or  circular,  is  oval, 
bent  to  a  greater  angle,  with  a 
slight  oval  on  each  side.  It  is  in- 
tended more  particularly  for  car- 
rying small  masses  of  crystalline 
or  sponge  gold  to,  and  pressing 
them  in,  the  orifices  of  cavities  in  the  approximal  surfaces  of 
teeth  slightly  separated  from  each  other.  It  is  better  adapt- 
ed for  this  purpose  than  any  instrument  at  present  used. 

The  surfaces  of  the  working  ex-  Fig.  hi.  Fig.  112.  Fig.  lis. 
tremities  of  both  of  the  foregoing  in- 
struments, as  indeed  are  all  that  are 
used  for  filling  teeth  with  these  prepa- 
rations of  gold,  are  cross  cut,  forming 
upon  them  numerous  fine  sharp  points. 
Several  sizes  of  the  one  last  as  well  as 
the  one  first  described  are  needed. 


*  A  series  of  the  most  approved  forms  that  have  been  gotten  up  for  the  pnrpose, 
are  represented  in  an  article  by  Dr.  W.  H.  Dwinelle,  published  in  the  April  No.  of 
Vol.  5,  New  Series,  of  the  American  Journal  of  Dental  Science.  Most  of  the  cuts 
in  this  chapter  are  copied  from  them. 

t  The  instruments  represented  in  Fig.  109,  are  from  patterns  gotten  up  Dr.  Wm , 
M.  Hunter,  of  Cincinnati,  Ohio. 

24 


362 


INSTKUMENTS   EMPLOYED   IN   FILLING   TEETH. 


In  Fig.  Ill  is  seen  a  representation  of  an  instrument 
slightly  bent  at  the  working  extremity — the  upper  surface 
of  which  is  flat^  and  terminates  in  a  blunt  point.  It  is  de- 
signed chiefly  for  introducing  and  compressing  the  gold  in 
the  grinding  surface  of  molar  teeth,  both  of  the  upper  and 
lower  jaws.  Fig.  112  represents  an  instrument  having  the 
general  form  of  the  one  last  described,  but  filed  out  on  the 
under  surface,  as  shown  in  the  cut ;  the  point,  being  promi- 
nent^ is  intended  to  be  introduced  a  short  distance  into  cavi- 
ties in  the  posterior  approximal  surface  of  molar  and  bicus- 
pid teeth.  It  is  one  which  may  be  advantageously  em- 
ployed in  many  cases.  Several  sizes,  however,  both  of  this 
and  the  preceding  one,  are  required,  with  slight  modifica- 
tions of  form.  The  instrument  represented  in  Fig.  113,  is 
designed  for  introducing  gold  in  cavities  in  the  approximal 
surfaces  of  incisor  and  cuspid  teeth,  and  for  which  purpose 
it  is  peculiarly  adapted. 
Fig,  114.  Fig.  115.  The  instruments  represented  in  Fig. 
114,  are  said  to  be  very  useful  in  filling 
cavities  in  the  approximal  surfaces  of 
teeth_,  and  judging  from  their  appear- 
ance, we  have  no  doubt  they  may  be 
very  advantageously  used  in  many 
cases.*  The  instrument  represented  in 
Fig.  115,  and  of  which  several  are  re- 
quired, varying  in  size  and  bent  at  difierent  angles,  is 
chiefly  employed  in  filling  cavities  in  the  approximal  sur- 
faces.    The  working  extremity  is  serrated. 

Fig.  iiG.  Fig.  117.  Instruments   with   their 

working  extremities  bent 
to  various  angles,  and  of 
difierent  lengths  and  sizes, 
some  reduced  nearly  to  a 
sharp  point,  like  those  rep- 
resented in  Fig.  116,  are 
^■|j|       Wl        required    in    consolidating 

*  These  instruments  were  gotten  up  by  Professor  Arthur. 


INSTRUMENTS   EMPLOYED   IN   FILLING   TEETH. 


363 


FiQ.  118. 


the  gold  in  cavities  of  the  grinding,  approximal  and  buccal 
surfaces.  The  points  may  be  round  or  flat,  as  may  suit  the 
fancy  of  the  operator.  A  description  of  an  instrument,  like 
the  one  represented  in  Fig.  117,  will  also  be  found  very 
useful  in  condensing.  Points,  however_,  much  smaller  than 
the  smallest  here  represented^  bent  to  several  different  an- 
gles, are  needed. 

The  instruments  shown  in  Fig. 
118,  are  used  for  introducing  and 
partially  compressing  gold  in  ap- 
proximal cavities.  The  working 
exremities,  as  seen  in  the  cut,  form- 
ing a  right  angle  with  the  stem 
of  the  instrument,  should  vary  in 
length  and  diameter,  from  the 
largest  here  figured,  to  the  most  delicate  dimensions,  to  be 
made  available  in  the  various  cases  in  which  their  use  may 
be  required. 

An  instrument  with  working  points  some-        Fio.  ii9. 
what  like  those  shown  in  Fig.  118,  with  the 
stem  bent  to  a  lateral  angle^  a  short  distance 
above  the  serrated  extremity,  is  represented 
in  Fig.  119.     When  bent  in  this  way,  they 
are  made  in  pairs,  one  for  the  right  and  one 
for  the  left  side,  and  as  with  the  instruments 
before  described,   they  should  vary  in  size. 
For  introducing  and  partially  condensing   gold  in  approxi- 
mal cavities  in   the  oral  and  bicuspid  teeth,  they  are  pecu- 
liarly well  adapted.     The  author  Fiq.  120. 
has  a  set  made  from  patterns  got- 
ten  up   by   Dr.  Ballard,  of  New 
York,  which,  for  this  purpose,  he 
has  found  more   serviceable   than 
any   other   description   of   instru- 
ment. 

The  instruments  in  Fig.  120  are 
used  in  introducing  and  partially  compressing  gold  in  ante- 


364 


INSTRUMENTS   EJVIPLOYED   IN   FILLING   TEETH. 


rior  and  posterior  approximal  cavities  of  molar  and  bicus- 
pid teetli ;  but  instruments  of  this  description  have  been 
used  by  dentists  for  many  years  for  condensing  gold  foil, 
but  they  may  be  employed  more  advantageously  in  working 
crystalline  gold.  It  is  only,  however,  in  the  earlier  stages 
of  the  operation  that  they  can  be  very  efficiently  used,  un- 
less the  working  extremity  be  very  small. 

Fig.  121. 


I 


In  Fig.  121,  instruments  with  variously  shaped  points  are 
represented.  Some  of  them  are  mere  modifications  of  a  few 
of  those  previously  described.  But  in  the  use  of  crystalline 
and  sponge  gold,  they  will  all  be  found  very  useful. 

Fig.  122.  The  instruments  represented  in 

Fig.  122,  are  some  the  author 
had  constructed  for  partially  con- 
densing the  angles  around  the 
grinding  surface  of  a  tooth,  when 
he  finds  it  is  necessary  to  build 
up  the  whole  or  part  of  the  crown. 
With  instruments  like  these,  the 
particles  of  gold  are  pressed  to- 
gether and  partially  united,  the  side  and  grinding  surface 
being  both  acted  upon  at  the  same  time;  smaller  points 
may  be  afterwards  applied,  without  danger  of  crumbling  the 
mass  thus  built  up.  For  purposes  of  this  sort,  instruments 
like  these  are  very  useful. 

Other  forms  of  instruments  are  sometimes  employed  in 
the  use  of  sponge  gold,  but  one-fourth  of  those  even  here 
represented  will  be  found  amply  sufficient  for  most  opera- 
tions, and  hence  it  has  not  been  deemed  necessary  to  give  a 
more  extended  description. 


INTRODUCING  AND   CONSOLIDATING   THE  GOLD.  365 


INTRODUCING   AND   CONSOLIDATING   THE   GOLD. 

In  filling  teetli  with  crystalline  or  sponge  gold,  the  cavity 
in  the  tooth  is  prepared  in  the  manner  as  described  when 
leaf  gold  is  employed.  This  done,  the  gold  is  cut  into 
small  pieces,  varying  in  size  according  to  the  dimensions  of 
the  cavity  and  the  particular  stage  of  the  operation  in  which 
it  is  to  be  used.  It  being  important  that  the  crystals  or 
particles  composing  the  mass,  should  be  as  little  separated  or 
displaced  as  possible,  before  the  piece  is  carried  to  its  place 
in  the  tooth ;  it  should  be  used  in  as  large  pellets  as  can  be 
introduced  into  the  cavity  without  crumbling. 

The  gold  being  cut  into  pieces  of  the  proper  size,  the 
cavity  is  washed,  and  then  wiped  dry  with  prepared  raw 
cotton  or  spongy  tissue  paper,  a  piece  of  gold,  as  large  as 
the  orifice  of  the  cavity  will  receive,  is  placed  over  it  with 
suitable  pliers  or  one  of  the  instruments  represented  in  Fig. 
109,  or  Fig.  110,  as  may  be  most  convenient,  which  is  well 
adapted  to  the  purpose — the  spongy  mass  readily  adhering  to 
the  serrated  surface  of  the  working  extremity,  when  pressed 
gently  upon  it,  and  with  which  it  may  also,  in  most  cases, 
be  carried  to  the  bottom.  Every  part  is  now  thoroughly 
consolidated,  first  with  a  large,  and  next  with  a  smaller, 
and  lastly  with  a  very  delicate-pointed  instrument,  so  bent 
that  it  may  be  readily  applied  to  all  the  depressions  and  in- 
equalities of  the  walls  and  floor  of  the  cavity ;  for  unless  the 
gold  is  made  absolutely  solid  in  these  places,  as  well  as 
throughout  all  the  parts  of  the  filling,  the  success  of  the  ope- 
ration will  be  more  or  less  uncertain.  Thus,  piece  after  piece 
is  applied,  consolidating  each  one  as  the  operation  pro- 
gresses, until  the  gold  protrudes  sufficiently  from  the  orifice 
of  the  cavity  to  admit  of  a  good  finish,  leaving  the  surface 
flush  with  the  surface  of  the  tooth. 

If,  during  any  part  of  the  operation,  the  smaller  pointed 
instruments  can  be  forced  between  the  gold  and  the  walls  of 
the  cavity,  such  opening  or  openings,  if  more  than  one  is 
made,  should  be  filled  with  smaller  masses  of  the  material 


366  INTRODUCING  AND   CONSOLIDATING   THE  GOLD. 

before  another  large  one  is  introduced.  This  precaution 
ought  never  to  be  neglected,  for  should  any  soft  places  exist 
after  the  completion  of  the  operation,  the  filling  will  be 
liable  to  absorb  moisture  and  ultimately  to  crumble  and 
come  out.  It  is  also  necessary,  as  we  have  before  stated, 
that  the  gold,  during  the  introduction  of  it  into  the  tooth, 
be  kept  absolutely  free  from  moisture,  as  this  destroys  the 
welding  or  uniting  properties  of  the  crystals. 

The  gold  having  been  introduced  and  consolidated  as 
directed,  the  exposed  surface  is  scraped  or  filed  down  to  a 
level  with  the  orifice  of  the  cavity,  then  made  smooth  by 
rubbing  it  with  Arkansas  rock  or  oil  stone,  or  with  finely 
powdered  pumice,  and  burnished  or  polished  with  crocus,  in 
the  manner  as  described  when  gold  foil  is  used. 

In  finishing  a  filling  made  with  these  preparations  of  gold, 
the  operator  should  see  that  there  are  no  thin  overlapping 
portions  upon  the  teeth  outside  of  the  orifice  of  the  cavity, 
as  they  are  liable,  in  biting  hard  substances,  or  in  masti- 
cation, to  be  broken  ofi",  leaving  a  dei^ression  to  serve  as  a 
lodgment  for  extraneous  matter  and  clammy  secretions, 
which,  sooner  or  later,  according  to  the  density  of  the  tooth, 
will  give  rise  to  a  softening  of  the  dentine  thus  exi)osed, 
which,  if  it  does  not  cause  the  filling  to  loosen,  will  ulti- 
mately render  its  removal  and  the  replacement  of  it  neces- 
sary. In  short,  the  precautions  necessary  to  be  observed  in 
making  a  filling  with  gold  foil  should  be  as  carefully 
attended  to  when  the  operation  is  made  with  either  of  the 
preparations  now  under  consideration. 

We  might  enlarge  upon  this  part  of  our  subject,  by  going 
into  detail  and  describing  the  various  manipulations  required 
to  fill  a  tooth  in  the  several  localities  in  which  the  operation 
may  be  called  for,  but  the  foregoing  general  directions,  it  is 
believed,  will  serve  as  a  sufficient  guide  to  the  dentist  in  the 
use  of  these  preparations  of  gold.* 


*  For  a  fuller  exposition  of  the  subject,  the  reader  is  referred  to  a  series  of  inter- 
estinp:  articles  by  Dr.  C.  W.  Ballard,  published  in  the  March,  April,  May  and  June 
numbers  for  1855,  of  the  New  York  Dental  Recorder,  and  to  the  article  previously 
referred  to  by  Dr.  Dwinelle. 


CHAPTER      EIGHTH. 

BUILDING  ON  THE  WHOLE  OR  PART  OF  THE  CROWN  OF 

A  TOOTH. 

Few  persons  have  the  patience  to  undergo  an  operation 
requiring  as  much  time  for  its  performance,  as  the  building 
on  of  the  whole,  or  a  large  part  of  the  crown  of  a  tooth,  and 
fewer  still,  are  willing  to  incur  the  expense  of  the  labor  and 
gold  necessary  to  make  one.  Hence,  it  is  seldom  attempted, 
and  can  only  be  performed  by  the  most  expert  and  skillful 
manipulators.  Nevertheless,  as  it  is  sometimes  made,  it 
would  not  be  proj)er  to  omit  a  description  of  the  manner  of 
doing  it.  It  is  scarcely  to  be  expected  however,  that  any 
one  who  has  not  had  considerable  experience  in  filling  teeth, 
and  acquired  a  high  degree  of  dexterity  in  the  use  of  instru- 
ments and  the  working  of  some  one  or  more  of  the  pre2:)ara- 
tions  of  gold  employed  for  the  purpose,  will,  simply  from 
any  directions  that  can  be  laid  down  upon  the  subject,  be 
able,  at  once,  to  make  the  operation.  But  it  is  hoped,  that 
the  following  description  may  serve  as  a  guide  to  those  who 
have  never  attempted  it  and  may  wish  to  exercise  their  me- 
chanical and  artistic  abilities  on  the  most  difficult  of  all  op- 
erations in  dentistry.  Those  only  who  are  aiming  at  high 
excellence  in  this  department  of  practice,  will  be  likely  to 
undertake  it,  and  should  their  first  efforts  prove  unsuccess- 
ful,, the  increase  of  skill  they  will  have  thus  acquired  in  the 
use  of  instruments,  will  inspire  new  confidence,  and  ultimate- 
ly, by  perseverance,  enable  them  to  achieve  the  object  of  their 
wishes. 

The  operation  to  be  successful  must  not  only  be  perform- 
ed in  the  most  perfect  manner  but  the  tooth   al  io  must   be 


368  BUILDING   ON   THE   CROAVN    OF    A   TOOTH. 

situated  in  a  healthy  socket  and  firmly  articulated.  Under 
other  circumstances  it  would  he  useless  to  attempt  the  res- 
toration of  the  organ.  The  general  system  too,  should  be 
free  from  preternatural  susceptibility  to  morbid  impressions. 

A  tooth  on  which  the  operation  is  called  for,  has,  in  near- 
ly every  case,  suffered  so  much  loss  of  substance  as  to  in- 
volve exposure  of  the  pulp,  and  consequently  the  destruction 
and  removal  of  this,  is  the  first  thing  to  be  attended  to, 
unless  as  is  sometimes  the  case,  it  has  previously  perished 
from  inflammation  and  suppuration.  When  this  has  hap- 
pened, the  permanent  preservation  of  the  organ  cannot  be 
counted  on  with  as  much  certainty  as  when  it  is  destroyed 
by  the  application  of  an  escharotic  two  or  three  days  before 
the  performance  of  the  operation.  Its  destruction  by  the 
suppurative  process  is  more  apt  to  be  followed  by  alveolar  ab- 
scess, and  this  having  once  established  itself,  is  seldom  so 
completely  cured  as  to  prevent  the  liability  of  its  recurrence. 
But  if  the  operation  is  still  determined  on,  the  parts  at  the 
extremity  of  the  root,  must  first  be  restored  to  health,  and 
failing  to  accomplish  this,  it  should  not  be  attempted.  The 
treatment  in  cases  of  this  sort,  as  well  as  of  simple  morbid 
secretion  escaping  from  the  fang,  is  described  in  another 
chapter. 

In  describing  the  operation  we  will  commence  with  the 
first  molar  of  the  left  side  of  the  superior  maxillary.  We 
will  suppose  that  about  three-fourths  of  the  crown  has  been 
destroyed  by  caries,  and  that  the  buccal  wall  is  the  only 
portion  remaining,  the  nervous  pulp  being  more  or  less  ex- 
posed. This  is  destroyed  and  extirpated  to  the  extremity 
of  each  root  in  the  manner  as  described  in  another  place. 
The  decaj'ed  portions  of  the  tooth  are  now  removed,  and  the 
central  chamber  enlarged  until  the  wall  of  dentine  on  the 
palatine,  anterior  and  posterior  approximal  sides  are  only 
about  one  line  in  thickness.  On  the  inside  of  this  wall,  a 
shallow  groove  or  undercut  is  made  to  give  additional  secu- 
rity to  the  gohl. 

The  tooth  as   now  prepared  is  represented  in   Fig.  123, 


BUILDING   ON   THE   CROWN    OF   A   TOOTH.  369 

and  having  proceeded  thus  far  with  the  operation,  the  intro- 
duction and  building  on  of  the  gold  may  be  commenced. 
But  before  describing  the  manner  of  doing  ^^^-  123. 
this,  it  may  be  well  to  say  a  few  words  with 
regard  to  the  preparation  of  gold  most  proper 
to  be  employed.  For  filling  the  roots,  the  foil 
ordinarily  used  is  the  best.  If  the  leaves  are 
thick,  weighing  from  fifteen  to  twenty  grains, 
it  should  be  introduced  in  very  narrow  strips, 
without  folding,  in  the  manner  as  described  in 
another  chapter  ;  if  leaves  of  four  or  six  grains  are  preferred, 
it  may  be  cut  in  strips  varying  from  an  eighth  to  a  quarter 
of  an  inch  iu  width,  according  to  the  size  of  the  canal  in  the 
root,  and  then  made  into  very  narrow  folds,  or  rolled  before 
using.  For  the  central  chamber  and  crown,  gold  possessing 
adhesive  properties  should  be  employed,  and  this  property 
may  be  imparted  to  common  gold  foil  by  slightly  annealing 
immediately  before  using  ;  but  foil  made  from  crystalline 
gold  possesses  it  in  a  higher  degree,  and  this  also  requires  to 
be  annealed.  Either  kind  of  foil,  therefore,,  or  crystalline 
gold,  may  be  employed.  The  operation,  however,  can  be 
made  with  less  labor  with  either  of  the  two  first  than  with 
the  last  named  preparation. 

The  manner  of  filling  roots  having  been  described  in 
a  preceding  part  of  this  work,  we  shall  commence  the  opera- 
tion with  the  pulp-cavity.  The  gold,  supposing  it  to  be  foil, 
is  cut,  each  leaf  of  No.  4  into  from  four  to  six  pieces,  which 
are  loosely  rolled  into  round  or  oval  pellets.  A  sufficient 
number  of  these  having  been  prepared,  the  surfaces  against 
which  the  gold  is  to  be  placed  are  made  perfectly  dry  by 
wiping  with  tissue  or  bibulous  paper,  or  raw  cotton.  This 
done,  one  of  the  pellets  or  balls  is  placed  in  the  central  cham- 
ber with  pliers,  and  partially  consolidated  with  a  small  point- 
ed integrating  instrument,  another  and  another  is  added, 
each  being  consolidated  as  the  first,  until  a  sufficient  number 
have  been  introduced  to  obtain  the  necessary  mechanical  sup- 
port from  the  surrounding  wall  of  dentine  to  prevent  any 


370  BUILDING    ON   THE   CROWN    OF   A    TOOTH. 

portion  from  being  moved  from  the  i^lace  it  is  first  made  to 
occupy.  The  process  of  consolidation  is  now  repeated  and 
continued  until  no  part  of  the  gold  can  be  made  to  yield  to 
the  pressure  of  the  instrument,  when  additional  pellets  are 
applied  and  condensed  as  in  the  first  instance,  until  the 
pulp-cavity  is  completely  filled,  forcing  those  placed  against 
the  surrounding  wall  firmly  and  compactly  into  the  groove 
or  undercut  made  in  it,  thus  securing  for  the  entire  mass  the 
greatest  possible  stability.  Agaiu^  pellet  after  pellet  is 
applied,  pressing  those  placed  along  the  outer  edge  of  the 
gold  already  occupying  the  central  chamber  firmly  against 
the  exjiosed  margin  of  dentine  and  the  buccal  wall  of  the 
tooth,  until  a  solid  mass,  considerably  larger  than  the 
portion  of  the  crown  to  be  supplied  shall  have  been  thus 
formed. 

For  the  complete  solidification  of  every  part  of  the  gold, 
and  the  welding  of  every  piece — the  one  to  the  other,  a 
number  of  instruments  are  required,  with  integrating 
points,  varying  in  size  from  the  one  represented  in  Fig.  99 
to  less  than  half  the  size  of  the  one  in  Fig.  96.  For  some 
portions  of  the  operation  a  straight  instrument  can  be  em- 
ployed most  advantageously  ;  for  other  parts  one  slightly 
bent  near  the  point,  and  for  others  one  bent  to  a  right  angle 
with  the  stem.  But  the  kind  that  can  be  most  efficiently 
nsed  must,  after  all,  be  determined  by  the  judgment  of  the 
operator  One,  perhaps,  may  use  very  efficiently  an  instru- 
ment in  a  jjarticular  locality  and  for  a  certain  purpose,  that 
another  for  the  same  purpose  would  handle  very  awkwardly. 
But  for  comi^leting  the  work  of  consolidating,  all  agree  that 
very  small  jiointed  instruments  are  indispensable. 

As  the  adhesiveness  of  the  gold  is  destroyed  by  the  con- 
tact of  liquids,  it  must  be  kept  absolutely  free  from  mois- 
ture during  the  entire  process  of  applying  and  consolidating 
the  metal.  But  if,  notwithstanding  all  the  precaution  the 
dentist  is  able  to  use,  the  saliva  should  come  in  con- 
tact with  the  operation  before  this  part  of  it  is  completed, 
the  gold  which  has  already  been  applied  must  be  thoroughly 


BUILDING    ON   THE    CROWN   OF   A   TOOTH.  3^1 

consolidated,  tlien  dried  with,  bibulous  paper  or  some  other 
good  absorbing  substance,  the  surface  scraped,  burnished, 
dried  again,  and  made  rough  with  a  sharp-pointed  instru- 
ment— one  like  those  used  by  engravers  will  be  found  best 
adapted  to  the  purpose.  To  tliis  surface  other  portions  of 
gold  may  be  united,  and  the  ojDeration  from  this  point  carried 
on  to  completion. 

Having  arrived  at  this  stage  of  the  operation,  the  next 
thing  to  be  done  is  to  consolidate  thoroughly  every  part  of 
the  surface.  This  may  be  commenced  with  the  larger 
pointed  integrating  instruments.  After  going  over  it  ten 
or  a  dozen  times  with  these,  smaller  points  may  boused,  and 
these  again  changed  for  still  smaller,  and  so  on  until  no  ap- 
preciable impression  can  be  made  upon  any  part  of  the  gold. 

It  now  remains  to  file  and  scrape  the  surface  until  the 
gold  is  made  to  assume  very  nearly  the  shape  of  that  portion 
of  the  original  tooth,  the  loss,  of  which  it  supplies.  In 
doing  this  an  opportunity  is  afforded  the  operator  of  display- 
ing his  artistic  skill  and  ingenuity — his  ability,  in  short,  to 
copy  nature.  While  shaping  the  grinding  surface,  the 
patient  should  be  requested  from  time  to  time  to  close  his 
mouth,  that  the  depressions  in  it  may  be  made  of  the  proper 
size  and  shape  for  the  reception  of  the  protuberances  of  the 
tooth  with  which  it  antagonizes,  that  these  two  may  touch 
at  the  same  instant  the  other  teeth  of  the  upper  and  lower 
jaws  come  together.  This  part  of  the  operation  is  always 
tedious,  usually  requiring  more  time  than  for  the  consoli- 
dation of  the  gold. 

The  operation  being  reduced  to  the  required  ^^i!i' 
size  and  form,  the  surface  of  the  gold  may  be 
rubbed  with  properly  shaped  pieces  of  Arkansas 
or  Lake  Superior  rock,  or  finely  pulverized 
pumice,  until  all  tlie  scratches  left  by  tlie  file 
are  removed.  It  is  then  polished  with  crocus 
or  a  burnisher.  The  appearance  of  the  tooth 
as  now  restored  ma}'"  be  seen  in  Fig.  124. 

As  it  is  impossible  to  perform  the  entire  operation  at 


372  BUILDING   ON   THE   CROWN   OF   A   TOOTH. 

one  time,  it  may  readily  be  divided  into  three  parts.  The 
first  may  consist  in  the  extirpation  of  the  nervous  pulp  and 
the  preparation  of  the  tooth  ;  the  second,  in  the  application 
and  solidification  of  the  gold  ;  the  third,  in  giving  to  the 
metal  the  proper  conformation  and  finishing  the  surface. 
The  time  required  for  the  first,  supposing  the  operation  to 
be  like  the  one  just  described,  may  vary  from  one  and  a  half 
to  two  and  a  half  hours  ;  for  the  second,  from  two  to  three 
and  a  half  hours,  and  for  the  third,  from  two  to  six  hours, 
according  to  the  difiiculties  that  maybe  encountered  during 
the  progress  of  its  performance,  the  ability  of  the  dentist, 
and  the  completeness  of  his  preparation  for  it. 

Some,  perhaps,  may  prefer  crystalline  or  spongy  gold, 
supposing  the  crystals  or  granules  are  more  easily  united, 
one  to  another,  tlian  the  surfaces  of  adhesive  foil  ;  but  as 
the  manner  of  working  these  preparations  has  already  been 
described,  it  will  not  be  necessary  to  give  additional  direc- 
tions upon  the  subject.  The  operation  of  building  on  the 
crown  or  part  of  the  crown  of  a  tooth,  should,  for  the  most 
part,  be  proceeded  with  in  the  same  way  with  the  one  as 
with  the  other.  If  too  large  a  piece  of  either  is  used  at 
one  time,  the  surface  will  become  crusted  over  by  the  pres- 
sure of  the  point  of  the  instrument,  and  prevent^  by  any 
subsequent  force  that  can  be  safely  applied,  its  thorough 
consolidation.  In  this  case,  the  general  mass  will  be  more 
or  less  spongy  and  the  operation  imperfect.  The  dentist 
should  be  well  assured,  therefore,  as  he  progresses  with  his 
work,  that  every  part  is  executed  in  the  most  thorough  and 
perfect  manner. 

As  the  same  system  of  manipulation  is  practiced  in  build- 
ing on  the  entire  crown  of  a  tooth  as  in  the  operation  just 
described,  it  will  not  be  necessary  to  recapitulate  what  has 
already  been  said  upon  the  subject.  A  dentist  who  can  do 
one,  can  also  do  the  other.  The  only  difierence  is  in  the 
time  occupied  in  making  the  respective  operations.  The 
first,  of  course,  requires  more  than  the  second. 

A  large  portion  of  the  crown  of  a  tooth  may  be  built  up 


BUILDING   ON   THE  CROAYN  OF   A   TOOTH.  373 

with  ordinary  gold-foil,  if  it  be  of  the  best  quality ;  but  the 
adhesive  preparations,  whether  in  leaf  or  in  the  crystalline 
or  spongy  form_,  are  preferable. 

It  is  more  difficult  to  build  on  the  crown  of  a  tooth  in  the 
lower  than  in  the  upper  jaw_,  owing  to  the  increased  lia- 
bility of  the  locality  to  be  encroached  upon  by  the  fluids  of 
the  mouth. 

We  have  endeavored,  in  the  foregoing  description,  to 
point  out  the  general  method  of  procedure  in  the  operation 
on  which  we  have  been  treating.  We  have  also  noticed 
some  of  the  precautions  necessary  to  be  observed — but  un- 
expected difficulties  are  sometimes  encountered — the  pecu- 
liar nature  of  which  it  is  impossible,  a  prio7'i,  to  describe. 
Few,  however,  are  of  so  formidable  a  character  that  they 
cannot  be  overcome. 


CHAPTER     NINTH. 

TOOTII-ACHE. 

Pain  in  a  tooth,  tooth-ache,  or  odontalgia,  as  it  is  techni- 
cally termed,  is  a  symptom  of  some  functional  or  structural 
disturbance,  either  of  the  organ  in  which  the  pain  is  seated, 
or  of  some  other  part  or  parts  of  the  body  ;  but  more  fre- 
q[uently  of  the  former  than  of  the  latter.  But  so  variable 
is  the  character  of  the  sensation,  that  any  description  Avould 
fail  to  convey,  to  one  who  has  never  experienced  it,  a  correct 
idea  of  its  nature.  The  jjain  sometimes  only  amounts  to 
slight  uneasiness  ;  at  other  times  the  agony  is  almost  insup- 
portable. It  may  be  dull,  deep  seated,  borings  throbbing, 
or  lancinating.  It  may  be  slight  at  first,  gradually  increas- 
ing in  severity  until  it  amounts  to  the  most  excruciating 
torture,  or  it  may  come  on  without  any  premonition  what- 
ever. It  may  be  confined  to  a  single  tooth,  or  it  may  afiect 
several  at  the  same  time.  It  may  commence  in  one  tooth, 
and  pass  from  thence  to  another,  and  continue  until  every 
one  in  turn  has  been  attacked.  It  may  continue  for  hours 
and  days  without  scarcely  any  cessation,  or  it  may  be  inter- 
mittent^ the  paroxysms  recurring  at  stated  or  uncertain 
intervals,  and  each  lasting  from  thirty  minutes  to  one,  two, 
or  more  hours. 

CAUSES. 

The  causes  of  tooth-ache  are  almost  as  numerous  as  are 
the  varieties  of  character  which  it  exhibits.  Irritation  and 
and  inflammation  of  the  pulp,  and  inflammation  of  the  in- 
vesting membrane  are  among  the  most  frequent,  but  it  is 
sometimes  referable  to  a  morbid  condition  of  the  nerve  or 


CAUSES   OF  TOOTH- ACHE.  375 

nerves  going  to  a  single  tooth,  or  of  'Hhe  trunk  from  which 
several  teeth  are  supplied,"  also,  to  derangement  of  the 
digestive  organs,  to  increased  nervous  susceptibility  of  the 
uterus  resulting  from  pregnancy,  amenorrhoea,  &c.,  and  to 
certain  diatheses  of  the  general  system. 

Dr.  S.  P.  Hullihen  enumerates  the  following  as  the 
causes  of  tooth-ache ;  1,  exposure  of  the  nerve  ;  2,  fungus 
of  the  nerve;  3,  confinement  of  pus  in  the  internal  cavity; 

4,  a  diseased  state  of  the  periosteum  covering  the  fang,  and 

5,  sympathy.*  Dr.  Heilden  attributes  it  to  congestion  or 
inflammation,  or  a  leison  of  innervation  of  the  lining  mem- 
brane and  pulp,  or  of  the  peridental  membrane. f 

Inflammation  of  the  lining  membrane  and  pulp,  may  be 
produced  by  a  blow  upon  a  tooth,  or  by  powerful  imj)res- 
sions  of  heat  and  cold  communicated  through  the  conduct- 
ing medium  either  of  the  enamel  and  dentine  or  of  a  metal- 
lic filling  ;  but  it  is  more  frequently  occasioned  by  pressure 
and  the  direct  contact  of  irritating  agents,  such  as  carious 
portions  of  the  tooth,  particles  of  alimentary  substances, 
acrid  humors  and  other  irritating  external  bodies.  But  in- 
flammation is  not  always  a  necessary  consequence  of  impres- 
sions of  this  sort.  Pain  may  be  produced  by  them  when  it 
does  not  exist,  but  in  this  case  it  usually  subsides  soon  after 
the  removal  of  the  irritant.  Indeed  the  pulp  of  a  tooth 
may  be  exposed  for  months^  and  subjected  several  times 
every  day  to  the  contact  of  foreign  substances,  without  be- 
coming the  seat  of  inflammatory  action,  and  in  the  absence 
of  which,  the  pain,  though  coming  on  with  the  suddenness 
of  an  electric  flash,  and  often  of  the  most  excruciating 
kind,  is  seldom  of  long  duration. 

But  when  inflammation  exists,  the  pain,  which  at  first, 
amounts  only  to  a  slight  gnawing  sensation,  is  more  con- 
stant ;  after  a  while,  it  assumes  a  throbbing  character,  and 
if  not  promptly  arrested,  it  increases  in  severity  and  con- 
tinues until  suppuration  of  the  lining  membrane  and  pulp 

*  American  Journal  of  Dental  Science,  vol.  i,  p.  106. 
t  Half-yearly  Abstract  of  Medical  Science,  vol.  i,  1846. 


376  CAUSES   OF  TOOTH-ACHE, 

takes  place.  So  long  as  it  is  confined  to  the  parts  within 
tlie  pulp-cavity,  the  pain  is  not  increased  by  pressure  on  the 
tooth,  nor  is  the  tooth  started  from  the  socket,  as  it  is  in 
periodontitis.  The  locality  of  the  inflammation  may  also 
he  distinguished  by  the  fact,  that  cold  water  or  ice  applied 
to  the  tooth,  generally  gives  relief.  But  the  inflammation 
rarely  confines  itself  long  to  the  interior  of  the  tooth  ;  it 
usually  soon  extends  to  the  periosteum  of  the  root,  and  al- 
veolus, when  a  somewhat  different  train  of  phenomena  are 
developed.  Suppuration,  however,  having  taken  place,  an 
abscess  soon  forms  at  the  extremity  of  the  root. 

The  severity  of  the  pain  attending  odontitis,  as  inflam- 
mation of  the  pulp  is  technicall}^  termed,  from  the  supposi- 
tion that  every  part  of  the  organ  is  involved  in  the  dis- 
eased action,  is_,  doubtless,  owing  to  the  fact  that  this  ex- 
ceedingly sensitive  structure,  as  its  vessels  become  injected 
with  blood,  is  prevented  from  expanding  by  the  unyielding 
nature  of  the  walls  of  the  cavity  in  which  it  is  situated. 
Its  caj)illaries  being  thus  distended,  must  as  a  necessary 
consequence,  press  upon  the  nerves  which  are  everywhere 
distributed  upon  it,  and  the  excruciatingly  painful  throb- 
bing sensation  by  which  this  variety  of  tooth-ache  is  charac- 
terized, is  produced,  we  have  no  doubt,  by  the  pulsation  of 
these  vessels  Avhich  takes  place  at  each  injection  from  the 
artery  supplying  them  with  blood.  Hence,  increased  ac- 
tion of  the  heart  and  arteries,  from  whatever  cause  pro- 
duced, augments  the  pain,  which  is  also  more  severe  at 
night,  while  the  body  is  in  a  recumbent  posture,  than  dur- 
ing the  day.  The  phenomena  attending  the  inflammation, 
however,  are  influenced  very  much  by  the  condition  of  the 
tooth  and  the  habit  of  body  of  the  patient. 

When  the  inflammation  is  acute,  it  extends  to  every  part 
of  the  pulp  and  lining  membrane.  It  also  occurs  more  fre- 
quently before  than  after  these  tissues  have  become  exposed, 
and  generally  terminates  in  suppuration.  Chronic  inflam- 
mation usually  arises  from  partial  exposure  of  the  pulp,  and 
may  exist  for  months  without  being  attended  with  pain;  but 


CAUSES   OF   TOOTH- ACHE.  377 

the  pulp,  when  thus  effected,  is  more  susceptible  to  impres- 
sions of  heat  and  cold,  and  of  irritating  substances,  and  the 
liability  of  the  tooth  to  ache,  especially  at  night,  is  greatly 
increased. 

Tooth-ache  caused  by  acute  inflammation  of  the  invest- 
ing membrane,  is  characterized  by  pain,  at  first  dull,  after- 
wards acute  and  throbbing,  soreness  and  elongation  of  the 
tooth_,  redness  and  tumefaction  of  the  gums,  and  sometimes 
by  swelling  of  the  cheek,  indicating  the  formation  of  alve- 
olar abscess.  In  this  variety  of  odontalgia,  the  tooth  is 
often  so  much  raised  in  its  socket  as  to  interfere  more  or 
less  with  mastication. 

The  pain  attending  the  foregoing  pathological  condi- 
tions, when  severe  and  protracted,  is  often  accompanied  by 
constipation,  head-ache,  dryness  of  the  skin,  flushed  cheeks, 
fullness  and  increased  rapidity  of  pulse,  and  other  constitu- 
tional morbid  phenomena. 

The  nervous  susceptibility  of  the  teeth  is  sometimes  so 
much  increased  by  organic  and  even  functional  disturbances 
of  other  and  often  remote  parts,  that  the  mere  contact  of 
the  minute  nerves,  distributed  upon  the  pulp,  the  lining 
and  investing  membranes,  with  the  parts  with  which  they 
are  associated,  is  frequently  attended  with  severe  pain. 
This  variety  of  odontalgia  is  termed  sympathetic,  and  is  sup- 
posed to  be  the  result  of  the  transfer  of  nervous  irritation, 
or  more  properly,  we.  would  suppose^  of  exalted  excitability 
of  the  dental  nerves,  arising  from  a  morbid  condition  or 
functional  disturbance  of  some  other  part.  If  this  hypoth- 
esis be  true,  it  is  probable,  that  with  this  heightened  ner- 
vous excitability,  there  is  a  slight  increase  of  vascular 
action  in  the  pulp,  the  lining  and  investing  membranes  of 
the  tooth,  with  a  corresponding  increase  of  size  in  their 
capillaries^  and  in  consequence  of  which,  it  is  fair  to  presume, 
they  would  be  likely  to  exert  some  undue  pressure  upon  the 
nervous  filaments  supplying  these  tissues.  Though  pain, 
arising  from  this  cause,  may  have  its  seat  in  sound,  as  well 
26 


378  CAUSES  OF   TOOTH-ACHE. 

as  in  decayed  teeth,  it  occurs  more  frequently  in  the  latter 
than  the  former,  owing  to  the  fact  that  any  structural 
alteration  in  the  dentine,  adds  to  their  already  increased 
nervous  excitability. 

Persons  of  highly  excitable  nervous  temperaments,  preg- 
nant females,  and  individuals  laboring  under  a  deranged 
condition  of  the  digestive  organs  are  particularly  subject  to 
this  variety  of  tooth-ache.  It  also  sometimes  occurs  as  a 
symptom  of  rheumatism  or  gout,*  the  pain  in  cases  of  this 
sort,  assuming  the  specific  character  of  that  which  char- 
acterizes these  diseases.  Odontalgia  arising  from  other 
pathological  conditions  or  functional  disturbances  of  other 
parts,  assumes  a  great  variety  of  forms.  The  pain  may  be 
continued,  but  more  frequently  it  is  periodical.  It  may  be 
confined,  as  we  have  before  stated,  to  a  single  tooth_,  or  it 
may  attack  half  a  dozen  or  more  at  the  same  time,  the  pain 
assuming  every  variety  of  grade  and  character. 

In  what  is  termed  neuralgic  tooth-ache,  '^the  pain,"  says 
Dr.  Wood,  ''is  usually  of  the  acute  character,  sometimes 
mild  in  the  beginning,  gradually  increasing  in  intensity, 

*  A  most  remarkable  and  interesting  case  of  tooth-ache,  associated  with  gout, 
fell  under  the  observation  of  the  author,  in  May,  1850.  The  subject,  Mr.  W.,  a 
resident  of  Baltimore,  about  forty  years  of  age,  had  been  subject  to  attacks  of 
this  most  excruciatingly  painful  affection,  for  more  than  fifteen  years.  The  parox- 
ysms, for  some  four  or  five  years  previously  to  the  above  mentioned  time,  had 
occurred  at  intervals  of  from  three  to  six  months,  and  from  tea  to  twelve  days 
before  each  attack,  during  this  period,  he  suffered  from  pain  in  the  first  right 
superior  molar  tooth,  which  was  slightly  affected  with  caries  in  the  centre  of  the 
grinding  surface,  but  it  had  not  yet  penetrated  to  the  pulp-cavity.  The  pain  at 
first  was  not  severe,  but  it  gradually  increased  in  intensity,  and  assumed  a  pecu- 
liar boring,  and  at  times,  grinding  and  lancinating  character.  His  attacks  of 
gout  were  confined  to  the  joint  of  the  big  toe  of  his  right  foot,  and  as  soon  as  the 
pain  commenced  here,  it  subsided  in  his  tooth,  liut  when  the  paroxysm  of  gout 
began  to  pass  off,  it  agajn  commenced  in  the  tooth,  where  it  continued  for  about 
two  weeks. 

At  the  request  of  Mr.  W.,  we  removed  the  diseased  portion  of  the  tooth  and 
filled  the  cavity.  The  operation  for  about  three  months  promised  to  be  successful, 
but  about  ten  days  previously  to  the  next  paroxysm  of  gout,  the  tooth  began  to 
ache,  the  pain  subsiding  with  the  occurrence  of  the  paroxysm,  but  commencing 
again  when  it  had  passed  off,  and  continued  as  it  bad  formerly  done  for  about  two 
weeks.  His  suffering  from  the  pain  in  the  tooth  during  these  periods  was  so  great 
that  he  determined  to  have  it  extracted.     The  operation  was  successful. 


CAUSES   OF   TOOTH-ACHE.  379 

and  as  gradually  declining ;  but  usually  very  irregular,  at 
one   time  moderate,  at  anotlier    severe,  and    occasionally 
darting   with   excruciating    violence    through,   the   dental 
arches.     Kot  unfrequently  it  assumes  a  regular  intermittent 
form.     Instead  of  pain,  strictly  speaking,  the  sensation  is 
sometimes  of  that  kind  which  is  indicated  when  we  say  that 
the  teeth  are  on  edge,  and  is  apt  to  he  excited  by  certain 
harsh  sounds,  such  as  that  produced  in  the  filing  of  saAv 
teeth,  hy  mental  inquietude,  and  by  the  contact  of  acids  or 
other  irritant  substances.     Neuralgic  tooth-ache  sometimes 
persists,  with  intervals  of  exemption,  for  a  great  length  of 
time.     The  diagnosis  is  occasionally  difficult.    When,  how- 
ever, it  occurs  in  sound  teeth,  it  is  paroxysmal  in  its  char- 
acter, is  attended  with  little  or  no  swelling  of  the  external 
parts,    occupies   a   considerable   portion   of    the  jaw,    and 
especially  when  it  alternates  or  is  associated  with  pain  of 
the  same  character  in  other  parts  of  the  face,  there  can  be 
little  doubt  as  to  its  real  nature."     This  is  a  variety  of 
sympathetic  tooth-ache,  favored,  perhaps,  by  caries,  or  by 
the  manner  in  which  the  teeth  are  arranged  in  the  alveolar 
arch,  or  by  some  peculiar  susceptibility  of  the  parts  to  mor- 
bid impressions,   as  is  shown  by  the  fact,  that  the  pain 
almost  always  ceases  on  the  removal  of  all  causes  of  irrita- 
tion.    But  while^  on  the  other  hand,  pain  in  the  teeth  may 
be   caused   by   a   morbid    condition  of  other   parts,  other 
organs  frequently  sympathise  with  the  diseased  condition  of 
these,  and  become,  to  use  the  language  of  Mr.  Bell,  ''the 
apparent  seat  of  pain."     "I  have,"  says  this  writer,  ''seen 
this  occur  not  only  in  the  face,  over  the  scalp,  in  the  ear,  or 
underneath  the  lower  jaw,  but  down  the  neck,  over  the 
shoulder,  and  along  the  whole  lengtli  of  the  arm."     Cases 
of  this  sort  are  frequently  met  with. 

In  treating  of  tooth-ache.  Dr.  Good  observes:  "This  is 
often  an  idiopathic  affection,  dependent  upon  a  peculiar 
irritability,  from  a  cause  we  cannot  easily  trace,  of  the 
nerves  subservient  to  the  aching  tooth,  or  the  tunics  by 
which  it  is  covered,  or  the  periosteum,  or  the  fine  membrane 


880  CAUSES   OF   TOOTH-ACHE. 

that  lines  the  interior  of  the  alveoli.  But  it  is  more  fre- 
quently a  disease  of  sympathy,  produced  hy  pregnancy,  or 
chronic  rheumatism,  or  acrimony  in  the  stomach,  in  persons 
of  an  irritable  habit." 

"It  is  still  less  to  be  wondered  at,  that  the  nerves  of  the 
teeth  should  often  associate  in  the  maddening  pain  of  neu- 
r dig ia  faciei,  or  tic  douloureux,  as  the  French  writers  have 
quaintly  denominated  it,  for  here  the  connection  is  both 
direct  and  immediate.  In  consequence  of  this,  the  patient, 
in  most  instances,  regards  the  teeth  themselves  as  the 
salient  points  of  pain,  {and  they  unquestionably  may  he  so  in 
some  cases,)  and  rests  his  only  hope  of  relief  upon  extrac- 
tion ;  and  when  he  has  applied  to  the  operator,  he  is  at  a 
loss  to  fix  upon  any  one  point  in  particular.  Mr.  Fox  gives 
a  striking  example  of  this,  in  a  person  from  whom  he  ex- 
tracted a  stump  which  afforded  little  or  no  relief ;  in  conse- 
quence of  which  his  patient  applied  to  him  only  two  days 
afterwards  and  requested  the  removal  of  several  adjoining 
teeth,  which  were  perfectly  sound.  This  he  objected  to, 
and  suspecting  the  real  nature  of  the  disease,  he  imme- 
diately took  him  to  Mr.  (now  Sir)  Astley  Cooper,  who,  by 
dividing  the  affected  nerve,  produced  a  radical  cure  in  a  few 
days." 

The  author  is  acquainted  with  a  gentleman  similarly  af- 
fected. He  has  had  all  his  teeth  on  the  right  side  of  both 
jaws  extracted,  without  obtaining  any  relief. 

There  is  still  another  cause  of  tooth-ache,  which  we 
should  not  omit  to  mention ;  namely,  exostosis ;  but  from 
the  obscurity  of  the  diagnosis,  the  existence  of  the  aficction 
can  seldom  be  determined  with  positive  certainty,  except  by 
the  removal  of  the  tooth.  But  as  we  shall  hereafter  have 
occasion  to  treat  of  this  disease,  it  will  not  be  necessary  in 
this  place,  to  enlarge  upon  the  subject. 

Finally,  some  teeth,  from  peculiar  constitutional  idiosyn- 
crasy, are  more  liable  to  ache  than  others.  It  sometimes 
happens  that  every  tooth  in  the  mouth  is  destroyed  by 
caries    without   being    affected  with    pain,  while  at  other 


TREATMENT   OF   TOOTH-ACHE.  381 

times,  teeth  apparently  sound  become  the  seat  of  the  most 
agonizing  torture. 

TREATMENT. 

The  first  thing  to  be  attended  to  in  the  treatment  of 
tooth-ache,  is  the  removal  of  the  causes  which  have  given 
rise  to  it^  and  this  can  only  be  done  by  carrying  out  the 
curative  and  remedial  indications  of  the  morbid  conditions 
and  functional  disturbances  with  which  it  is  connected. 
While  these  continue,  it  will  be  impossible  to  obtain  per- 
manent exemption  from  pain.  The  sensibility  of  the  nerves 
supplying  a  tooth  may  often  be  obtunded,  and  the  pain 
palliated  by  the  application  of  stimulating  and  anodyne 
agents  to  the  exposed  pulp,  but  the  relief  thus  procured  is 
seldom  of  long  duration.  When  their  effects  subside,  the 
pain  usually  returns  with  increased  severity.  When  the 
pain  arises  from  chronic  inflammation  and  irritation  pro- 
duced by  external  agents  on  an  exposed  portion  of  the 
lining  membrane,  applications  of  this  sort  may  sometimes 
be  employed  with  great  advantage ;  and  among  those  which 
have  been  used  for  this  purpose  are  creosote,  the  oil  of 
cloves,  cinnamon,  cajeput,  etc.,  laudanum,  spirit  of  cam- 
phor, tannin,  ether  and  chloroform.  But  of  the  prepara- 
tions prescribed  by  the  author,  he  has  found  none  more  use- 
ful in  allaying  the  pain  than  the  following  : 

R    Sul.  ether,         §  i.         R  Sul.  ether,  §  i. 

Pul.  camph.      3ij.  Creosote,  3ss. 

Pul.  alum,        3ij.  Ext.  nut  galls,  si. 

Sul.  morphia,  9i  Misce.  Pul.  camph.  Sss.Misce. 

After  removing  all  foreign  matter  from,  and  carefully 
drying,  the  cavity  of  the  tooth,  a  small  bit  of  raw  cotton  or 
lint  dipped  in  either  of  the  above  may  be  applied,  and  re- 
newed several  times  a  day  if  necessary.  The  relief  ob- 
tained by  the  application  of  the  above  preparations,  is  in 


382  TREATMENT   OF   TOOTH-ACHE. 

he  majority  of  cases,  almost  instantaneous,  but  as  the  effect 
is  only  temporary^  a  recurrence  of  the  pain  is  liable  to  take 
place.  The  author  has  sometimes  used,  a  thick  solution  of 
gutta  perclia  in  chloroform.  The  application  of  a  drop  or 
two  of  this  to  the  exposed  pulp  is  usually  followed  by  imme- 
diate cessation  of  pain,  and  as  the  chloroform  evaporates,  a 
thin  layer  of  gutta  percha  remains  and  serves  for  a  time  as  a 
sort  of  protection  to  the  pulp. 

But  the  only  way  in  which  permanent  exemption  from 
pain  can  be  procured,,  is,  by  the  extraction  of  the  tooth  or 
the  destruction  of  the  pulp,  and  as  there  are  many  cases  in 
which  the  patient  cannot  be  prevailed  upon  to  submit 
to  the  former,  and  as  there  are  others  in  which  the.  re- 
tention of  the  organ  is  called  for  by  some  peculiar  necessi- 
ty, it  often  becomes  necessary  to  have  recourse  to  the 
latter.  This  may  be  effected  either  by  immediate  extir- 
pation with  a  small  sharp-pointed  elastic  stilet  or  probe,  the 
actual  cautery,  arsenious  acid^*  cobalt-,  or  chloride  of  zinc. 
But  immediate  extirpation^  arsenic  or  cobalt  are  the  means 
usually  emi)loyed  for  the  purpose^  and  as  we  have  described 
the  manner  in  which  the  destruction  of  the  pulp  is  effected 
by  each  of  these,  it  will  not  be  necessary  to  say  anything 
hereupon  the  subject. f 

Pain  in  a  tooth  arising  from  acute  inflammation  of  the 
pulp  and  lining  membrane,  can  only  be  removed  by  the  ex- 
traction of  the  tooth,  the  destruction  of  the  pulp,  or  by  sub- 
duing the  inflammatory  action,  and  the  last  can  seldom  be 
done  except  in  its  very  incipiency,  and  then,  only,  by  the 
most  energetic  treatment,  in  cases  where  the  decay  has  not 
penetrated  to  the  pulp-cavity.  The  propriety  or  improprie- 
ty of  extraction  will  be  determined  by  the  amount  of  pain, 
the  progress  made  by  the  inflammation,  the  condition  of  the 


*  The  employment  of  arsenious  acid  for  the  destruction  of  an  exposed  dental  pulp, 
and  the  relief  of  the  pain  arising  therefrom,  originated  with  the  late  Dr.  Spooner 
of  Montreal,   and  in  1835,  it  was  recommended  to  the  profession  by  his  brother,  Dr. 
S.  Spooner  of  New  York,  in  an  excellent  popular  treatise  upon  the  teeth, 
t  See  Filling  the  Pulp-cavities  and  Roots  of  Teeth. 


TREATMHNT   OF   TOOTII-ACHE.  383 

parts  witli  wliicli  the  tooth  is  immediately  connected,  the  ef- 
fect of  the  local  disturbance  upon  the  general  system,  the 
situation  and  importance  of  the  tooth,  and  the  extent  of 
structural  alteration  which  has  taken  place  in  the  crown. 
If  the  retention  of  it,  on  account  of  its  location,  or  the  loss 
cf  several  other  teeth,  is  of  great  importance  to  the  patient, 
and  the  circumstances  of  the  case  justify  a  well-grounded 
belief  that  it  can  be  preserved  and  rendered  useful,  without 
acting  as  a  morbid  irritant,  the  operation,  if  possible,  should 
be  avoided.  In  this  case,  supjDosing  the  inflammation  to 
have  proceeded  too  far  to  be  arrested,  the  pulp  may  be  de- 
stroyed and  tliQ  tooth  treated  in  the  manner  as  described  in 
another  chapter,  as  it  would  be  useless  to  procrastinate  the 
suffering  of  the  patient  by  instituting  other  treatment  in  the 
vain  hope  of  avoiding  an  alternative,  which,  after  all,  may 
not  enable  the  dentist  to  secure  the  permanent  preservation 
of  the  organ.  Indeed  after  the  lining  membrane  has  become 
exposed,  this  is  the  only  method  of  procedure,  in  any  stage 
of  the  inflammation,  which,  with  a  view  to  the  preservation 
of  the  tooth,  holds  out  any  prospect  of  success. 

When  the  inflammation  is  produced  by  other  causes  than 
exposure  of  the  pulp  and  contact  of  external  irritants,  it 
may  be,  sometimes,  successfully  combated.  The  treatment 
in  cases  of  this  sort,  is  similar  to  that  for  local  inflammation 
in  other  parts  of  the  body,  and  should  consist  of  saline  ca- 
thartics, leeches  to  the  gum  of  the  affected  tooth,  abstinence 
from  animal  food  and  stimulating  drinks.  If  the  pulse  is 
full  and  hard,  blood  may  be  taken  from  the  arm  with  ad- 
vantage. If  these  means  fail  to  arrest  it,  and  the  inflamma- 
tion be  permitted  to  continue  until  suppuration  takes  place, 
the  formation  of  alveolar  abscess  may  be  prevented  by 
promptly  perforating  the  crown  of  the  tootli  for  the  escape  of 
the  matter,  but  when  it  has  this  termination,  it  usually 
gives  rise  to  periodontitis,  which,  perhaps,  arise  as  frequent- 
ly from  this  as  any  other  cause. 

The  treatment  of  inflammation  of  the  investing  membrane 
is,  for  the  most  part,  the  same  as  above.     But,  in  addition 


384  TREATMENT   OF   TOOTH- ACHE. 

to  which,  the  mouth  may  be  gargled  several  times  a  day, 
with  some  cooling  astringent  wash.  Fomentations  to  the 
face  and  plasters  of  the  seeds  of  hyoscyamus,  mustard,  cap- 
sicum, or  other  narcotic  or  rubefacient  applications  have 
sometimes  been  found  useful.  But  when  the  formation  of 
alveolar  abscess  is  threatened,  the  removal  of  the  tooth,  in 
most  cases,  will  be  found  necessary.  If  it  be  an  incisor  or 
cuspidatus,  however,  the  operation  should  only  be  performed 
as  a  last  resort.  When  the  inflammation  is  chronic,  the 
necessity  for  the  removal  of  the  tooth  is  still  more  urgent. 

Tooth-ache  assuming  a  rheumatic  or  gouty  form  often  calls 
for  a  somewhat  different  plan  of  treatment.  In  addition  to 
the  local  means  already  described,  it  may  be  necessary  to 
adopt  the  constitutional  treatment  applicable  for  rheu- 
matism and  gout.  When  the  pain  arises  from  increased 
vascular  action  and  nervous  irritation  of  the  pulp,  occasioned 
by  a  disordered  condition  of  the  digestive  organs,  and 
assumes  an  intermittent  form,  an  emetic  or  cathartic, 
followed  by  the  use  of  quinine,  will  generally  afford  relief, 
provided  caries  has  not  penetrated  to  the  pulp-cavity.  If 
dependent  on  general  nervous  irritability  of  the  system, 
tonics,  exercise,  change  of  air,  and  such  other  constitutional 
measures  as  the  peculiarities  of  the  case  may  indicate, 
should  be  recommended. 

The  extraction  of  the  tooth  is  the  only  remedy  that  can 
be  relied  upon  for  relief  of  pain  arising  from  exostosis  of 
the  root.  Dr.  Good,  however,  thinks  it  may  be  cured  in  the 
early  stages  by  the  use  of  leeches  and  mercurial  ointment. 


CHAPTER    TENTH. 

EXTRACTION  OF  TEETH. 

There  are  few  operations  in.  surgery  that  excite  stronger 
feelings  of  dread,  and  to  wliicli  most  persons  submit  with 
more  reluctance,  than  to  the  extraction  of  a  tooth.  Many 
endure  the  tortures  of  tooth-ache  for  weeks  and  even  months 
rather  than  undergo  the  operation,  and,  when  we  take  into 
consideration  the  accidents  we  hear  of,  as  having  occurred  in 
its  performance  by  awkward  and  unskillful  individuals,  it  is 
not  surprising  that  it  should  be  approached  with  apprehen- 
sion. But  when  performed  by  a  skillful  hand  and  with  a 
suitable  instrument,  the  operation  is  always  safe,  and  in  a 
large  majority  of  the  cases^  may  be  effected  with  ease. 

Dr.  Fitch  relates  a  case  which  will  serve  to  illustrate  the 
the  above  remarks.  The  subject  was  a  man  residing  in 
Botetourt  county,  Virginia,  who,  in  having  the  second  supe- 
rior molar,  of  the  right  side,  extracted  by  a  blacksmith,  had 
a  large  portion  of  the  jaw  and  five  other  teeth  removed  at 
the  same  time.  "The  fangs  of  his  tooth,"  says  Dr.  F., 
'Svere  greatly  bifurcated  and  dove-tailed  into  the  jaw,  and 
would  not  pass  perpendicularly  out,  though  a  slight  lateral 
motion  would  have  moved  them  instantly.  The  jaw  proved 
too  weak  to  support  the  monstrous  pull  upon  it,  and  gave 
way  between  tlie  second  molar  tooth  and  first  molar,  and 
instantly,  both  the  anterior  and  posterior  plates  of  the 
antrum  gave  way.  The  fracture  continued  to  the  spongy 
bones  of  the  nose,  and  terminated  at  the  lower  edge  of  the 
socket  of  the  left  front  incisor,  carrying  out  with  the  jaw 
six  sound  teeth,  namely,  the  first  malar,  the  two  bicuspids, 
one  canine,  one  lateral,  and  one  front  incisor,  six  in  all. 


386  EXTRACTION   OF   TEETH. 

The  soft  parts  were  cut  away  with  a  knife.  A  severe  hem- 
orrhage ensued,  but  the  patient  soon  recovered,  though  with 
excessive  deformity  of  his  face  and  mouth,"* 

Dr.  Cross,  of  Jackson,  Northampton  county.  North  Caro- 
lina,, related  to  the  author  in  1838  a  case  so  very  similar  to 
the  one  just  quoted,  that  he  was  inclined  to  believe  it  was 
the  same,  until  he  recollected  that  the  one  occurred  in  Vir- 
ginia, and  the  other  in  the  county  in  which  Dr.  C.  resides. 
The  operator  in  this,  as  in  the  other  instance,  was  a  black- 
smith, Avho  in  attempting  to  extract  one  of  the  superior 
molar  teeth,  brought  away  a  piece  of  the  jaw,  containing 
five  other  teeth,  together  with  the  floor,  and  the  posterior 
and  anterior  walls  of  the  antrum.  The  piece  of  bone  thus 
detached  is  now  in  the  possession  of  a  physician  residing 
about  eight  miles  from  Jackson. 

We  have  adverted  to  these  cases,  merely  to  show  the  im- 
propriety and  danger  of  entrusting  the  operation  to  indi- 
viduals possessing  neither  knowledge  of  its  principles,  nor 
skill  in  its  performance.  Injuries  of  the  jaws,  occasioned  by 
the  operations  of  such  persons,  have  frequently  come  under 
the  immediate  observation  of  the  author,  to  whom  it  has 
always  been  a  matter  of  surprise  that  an  operation  to  which 
such  universal  repugnance  is  felt,  should  ever  be  confided  to 
such  persons. 

The  removal  of  a  wrong  tooth,  or  two,  or  even  three,  in- 
stead of  one,  are  such  common  occurrences,  that  it  were  well 
if  the  precautions  given  by  the  illustrious  Ambrose  Pare 
were  more  generally  observed.  So  fearful  was  he  of  injuring 
the  adjacent  teeth,  that  he  always  isolated  the  tooth  to  be 
extracted  with  a  file  before  he  attempted  its  removal.  He 
regarded  it  as  of  tlie  greatest  importance  that  a  person  who 
extracted  teeth  should  be  expert  in  the  use  of  his  ''tooth 
mullets  ;  for,"  says  he,  "unless  he  knows  readily  and  cun- 
ningly how  to  use  them,  he  can  scarcely  so  carry  himself, 
but  that  he  will  not  force  out  three  teeth  at  once. ' '    Although 

*  Fitch'a  Dental  Surgery,  p.  347. 


INDICATIONS  FOR   THE  EXTRACTION   OF  TEETH.  387 

great  improvements  have  been  made,  since  his  time,  in  the 
construction  of  instruments  for  the  extraction  of  teeth,  yet 
even  now  the  accidents  to  which  he  alludes  are  almost  of 
daily  occurrence. 

It  is  surprising  that  an  operation  so  frequently  called  for 
should  receive  so  little  attention  from  medical  practitioners, 
by  whom,  though  not  strictly  belonging  to  their  province, 
it  must  frequently  be  performed.  This  neglect  can  only  be 
accounted  for,  by  the  too  general  prevalence  of  the  supposi- 
tion, that  little  or  no  surgical  tact  is  necessary  for  its  per- 
formance. But  every  physician  residing  in  the  country,  or 
where  the  services  of  a  skillful  dentist  cannot  always  be  com- 
manded, should  provide  himself  with  the  proper  instruments 
and  make  himself  acquainted  with  the  manner  of  performing 
the  operation. 

INDICATIONS  FOR  THE  EXTRACTION  OF  TEETH. 

With  regard  to  the  indications  that  determine  the  pro- 
priety of  the  operation  in  question,  the  author  does  not  deem 
it  necessary  to  say  much,  in  this  place,  upon  tlie  subject,  as 
they  are  so  fully  pointed  out  rn  other  parts  of  the  work- 
But,  lest  some  of  them  be  overlooked,  he  will  briefly  men- 
tion, in  this  connection,  a  few  of  the  circumstances  whicb 
call  for  the  operation. 

Beginning  with  the  teeth  of  first  dentition,  it  will  be 
sufficient  to  state,  that  when  a  tooth  of  replacement  is  about 
to  emerge  from  the  gums,  or  has  actually  made  its  appear- 
ance, either  before  or  behind  the  corresponding  temporary, 
the  latter  should  at  once  be  removed  ;  and  when  the  aper- 
ture formed  by  the  loss  of  this  is  so  narrow  as  to  prevent  the 
former  from  acquiring  its  proper  position,  it  may  sometimes 
be  necessary  to  extract  an  adjoining  temporary  tooth  ;  but,  for 
more  explicit  directions  upon  this  subject,  the  reader  is 
referred  to  what  has  been  said  on  the  management  of  second 
dentition.  Alveolar  abscess,  necrosis  of  the  walls  of  the 
alveolus,  and  pain  in  a  temporary  tooth,  which  cannot  be 


388  INDICATIONS   FOR   THE  EXTRACTION   OF   TEETH. 

removed  by  any  of  the  usual  remedies,  may,  also,  be  re- 
garded as  indications  which  call  for  the  operation, 

Witli  regard  to  the  indications  which  should  determine 
the  extraction  of  a  permanent  tooth,  the  following  may  be 
mentioned  as  constituting  the  principal  : 

First,  when  a  molar,  from  the  loss  of  its  antagonizing 
tooth,  or  other  causes,  has  become  partially  displaced,  or  is 
a  source  of  constant  irritation  to  the  surrounding  parts,  it 
should  be  removed. 

Second,  a  constant  discharge  of  fetid  matter  through  a 
carious  opening  in  the  crown  from  the  nerve-cavity,  and  the 
canal  of  the  root  may,  also,  be  regarded  as  an  indication 
calling  for  extraction.  There  may,  however,  be  circum- 
stances which  would  justify  a  practitioner  in  yielding  to  the 
wishes  of,  or  even  advising  his  patient  to  permit  tlie  reten- 
tion of  such  a  tooth  ;  as,  for  example,  when  the  discharge 
of  fetid  matter  is  not  very  considerable,  and  the  tooth  is 
situated  in  the  anterior  part  of  the  mouth,  and  cannot  be 
securely  replaced  with  an  artificial  substitute.  The  secre- 
tion of  fetid  matter,  too,  may,  in  some  cases,  by  judicious 
treatment,  be  dried  up ;  in  this  case  the  tooth  may,  perhaps, 
be  preserved  for  many  j^ears,  by  plugging,  and  the  morbid 
influence  it  would  otherwise  exert  upon  the  surrounding 
parts,  be  counteracted.  But,  it  is  only  in  the  fewest  num- 
ber of  cases,  under  such  circumstances,  that  so  favorable  a 
result  can  be  secured.  A  front  tooth  should  not  be  sacri- 
ficed unless  called  for  by  some  very  urgent  necessity,  but 
neither  an  upper  incisor  nor  cuspidatus  should  be  permitted 
to  remain  in  tlic  mouth,  if  it  exerts  a  manifest  morbid  ac- 
tion upon  the  surrounding  parts.  In  this  case  the  efiects 
resulting  from  its  retention  in  the  moutli  are  worse  than  the 
loss  of  the  tooth. 

Third,  a  tooth  which  is  the  cause  of  abscess  in  its  alveo- 
lus, should  not,  as  a  general  rule,  be  permitted  to  remain 
in  the  mouth,  but,  as  in  the  case  last  described,  if  it  be  an 
incisor  or  cuspidatus,  and  the  discharge  of  matter  through 
the  gum  is  small,  occurring  only  at  long  intervals,  and,  es- 


INDICATIONS    FOR    THE   EXTRACTION    OF   TEETH.  389 

pecially,  if  the  organ  cannot  be  securely  replaced  with  an 
artificial  substitute,  it  maj^  be  advisable  to  permit  it  to  re- 
main. But  an  incurable  abscess  in  the  socket  of  a  bicus- 
pid or  molar,  may  be  considered  as  constituting  a  sufficient 
indication  for  the  removal  of  the  tooth. 

Fourth,  irregularity  in  the  arrangement  of  the  teeth, 
arising  from  disproportion  between  the  size  of  the  teeth  and 
alveolar  arch,  is  another  indication  calling  for  the  opera- 
tion. But  with  regard  to  the  teeth  most  proper  to  be  re- 
moved, the  reader  is  referred  to  the  chapter  on  irregularity 
of  these  organs.  Here  he  will  find  full  directions  for  the 
management  of  cases  of  this  kind. 

Fifth,  all  dead  teeth  and  roots  of  teeth_,  and  teeth  which 
have  become  so  much  loosened  from  the  destruction  of  their 
sockets  as  to  be  a  constant  source  of  disease  to  the  adjacent 
parts^  or  teeth  otherwise  diseased,  that  are  a  cause  of  neu- 
ralgia of  the  face,  a  morbid  condition  of  the  maxillary 
sinus,  dyspepsia^  or  any  other  local  or  constitutional  dis- 
turbance, should,  as  a  general  rule,  be  extracted. 

There  are  other  indications  which  call  for  the  extraction 
of  teeth,  but  the  foregoing  are  among  the  most  common, 
and  will  be  found  sufficient,  in  most  cases,  to  determine  the 
propriety  or  impropriety  of  the  operation.  Cases  are,  how- 
ever, continually  presenting  themselves,  to  which  no  rules 
that  could  be  laid  down  would  be  found  applicable,  and 
where  enlightened  judgment  alone  can  determine  the  prac- 
tice proper  to  be  pursued. 

In  conclusion,  it  is  scarcely  necessary  to  saj^,  that  when- 
ever a  tooth  can  be  restored  to  health,  it  should  always  be 
done,  but  tampering  with  such  as  cannot  be  rendered 
healthy  and  useful,  and  which,  by  remaining  in  the  mouth, 
exert  a  deleterious  influence,  not  only  upon  the  adjacent 
parts,  but  also  upon  the  general  health,  cannot  be  too 
strongly  deprecated. 


390  KEY   INSTRUJVIENT. 


INSTRUMENTS  EMPLOYED  IN  THE  OPERATION. 

Different  operators  employ  different  instruments.  For 
about  fifty  years,  tlie  key  of  Garengeot  was  almost  the  only 
instrument  used  in  the  performance  of  the  operation,  but 
recently,  this,  in  a  great  measure,  has  been  superseded  by 
forceps,  which,  when  properly  constructed,  are  far  prefera- 
ble ;  yet  as  the  key  is  still  used  by  some,  it  may  be  well  to 
give  a  brief  description  of  it. 

KEY    INSTRUMENT. 

''The  common  tooth-key,"  says  Dr.  Arnot,  "may  be 
regarded  in  the  light  of  a  wheel  and  axle  ;  the  hand  of  the 
operator  acting  on  two  spokes  of  the  wheel  to  move  it, 
while  the  tooth  is  fixed  to  the  axle  by  the  claw,  and  is 
drawn  out  as  the  axle  turns.  The  gum  and  alveolar  pro- 
cess of  the  jaw,  form  the  support  on  which  the  axle  rolls." 

Different  dentists  have  their  keys  diflerently  constructed, 
yet  the  principle  uj)on  which  they  all  act  is  precisely  the 
same.  Some  prefer  the  bent  shaft,  others  the  straight. 
Some  give  a  decided  preference  to  the  round  fulcrum,  others 
to  the  flat^  and  though  the  success  of  the  operator  depends 
greatly  upon  the  perfection  of  the  instrument,  yet  ho  can 
remove  a  tooth  more  exj)ertly  by  means  of  a  key  with  which 
he  is  familiar,  than  one  to  which  he  is  unaccustomed, 
though  its  construction  be  even  better. 

The  author  has  tried  almost  every  variety  of  key  instru- 
ment that  has  been  used  in  this  country,  and  he  is  of  opin- 
ion that  the  straight  shank  with  a  small  round  fulcrum^ 
slightly  flattened  on  each  side,  is  decidedly  preferable  to 
any  other.  The  objection  raised  to  the  use  of  such  a  key, 
by  some,  that  it  is  liable  to  interfere  with  the  front  teeth,  is 
without  good  foundation.  It  can  be  used  with  as  much 
safety  as  a  key  of  any  construction,  and,  in  most  cases,  can 
be  as  easily  applied.     The  round  is  certainly  preferable  to 


KEY   INSTRUMENT. 


391 


the  flat  fnlcrnm,  because  it  is  less  liable  to  injure  the  gums 
and  the  alveolus.  Its  size  should  be  a  little  larger  than  a 
half-ounce  bullet. 

Every  key  instrument  should  be  supplied  with  several 
hooks,  differing  in  size,  to  correspond  to  that  of  the  teeth  up- 
on which  they  are  to  be  applied.  The  hook  described  by  Dr. 
Maynard,*  is  preferable  to  any  which  the  author  has  seen. 
It  very  nearly  resembles  the  eagle's  claw^  except  that  its 
curvature  is  rather  greater.  The  edge  of  the  point  is  about 
the  sixteenth  of  an  inch  in  width,  and  divided  into  two 
points,  by  a  shallow  notch,  filed  in  the  centre.  A  hook  of 
this  description  is  less  liable  to  slip,  and  can  be  more  readi- 
ly ajjplied  to  a  tooth,  than  those  ordinarily  used. 

But  with  regard  to  the  merits  of  the  key  instrument, 
compared  with  the  forceps  presently  to  be  described,  the  au- 
thor does  not  entertain  a  very  high  opinion,  or  of  any  other 
instrument  having  the  same  principle  of  action.  The  fol- 
lowing remarks  quoted  from  the  late  work  of  M.  Desira- 
bode,  are  in  accordance  with  the  views  which  he  has  held 
and  promulgated  for  many  years. 

Fig.  125. 


In  treating  of  the  causes  of  fractures  of  the  alveoli,  he 
says,  '^one  of  the  most  common,  it  is  necessary  to  say  it, 
although  not  a  very  flattering  acknowledgment  from  our 
art,  is  a  badly  performed  operation  in  the  moutli,  and  if  it 


Fig.  125  represents  a  key  instrument  with  a  bent  shank  and  two  hooks,  one  for 
molar  and  one  for  bicuspid  teeth. 
*  See  Am.  Jour.  Dent.  Sci.  No.  3,  vol.  3. 


392  FORCEPS. 

is  necessary  to  specify  cases,  we  would  not  hesitate  to  quote, 
in  the  first  place,  the  use  of  the  key  of  Garengeot ;  for  we 
shall  prove,  in  treating  of  the  extraction  of  teeth,  that  this 
dangerous  instrument,  which  is  only  fit  to  mask  the  unskill- 
fulnes  of  the  operator,  to  the  detriment  of  the  operation,  is 
one  of  the  most  defective  of  surgical  instruments,  and  that 
no  practitioner  of  good  sense,  being  convinced  of  its  mode 
of  action,  would  attempt  to  employ  it  if  he  wished  to  ex- 
tract a  nail  from  a  hole,  if  he  did  not  desire  to  break  the 
wall." 

FORCEPS. 

Forceps  were  not  very  generally  or  extensively  employed, 
except  for  the  extraction  of  the  front  teeth,  until  about  the 
year  1830,  but  the  improvements  made  in  their  construction 
since  that  period,  are  so  great,  that  their  use  has  now^ 
among  dentists,  almost  altogether  superseded  that  of  the 
key. 

The  forceps  formerly  used,  were  so  awkwardly  shajjed, 
and  badly  adapted  to  the  teeth,  that  the  extraction  of  a 
large  molar  with  an  instrument  of  this  description,  was  re- 
garded as  so  exceedingly  difficult,  and  even  dangerous,  that 
its  practicability  was  doubted  by  many  of  the  most  expe- 
rienced practitioners,  and  hence,  the  key  was  almost  the 
only  instrument  resorted  to  for  the  purpose. 

When  we  consider  the  strong  prejudices  that  so  recently 
existed  to  the  use  of  forceps,  it  is  not  at  all  wonderful  that 
their  employment  should  have  been  resorted  tawith  caution. 
Nor  is  it  surprising  that  a  gentleman  of  Mr.  Bell's  intelli- 
gence and  practical  experience,  should,  so  late  as  the  period 
of  the  publication  of  his  work,  1830,  tell  us  that  the  key  is 
the  only  instrument  to  be  relied  on  for  the  removal  of  teeth 
that  are  much  decayed,  and  that  those  who  have  heaped  the 
most  opprobrium  upon  it,  are  glad  to  have  a  concealed  re- 
course to  its  aid. 

This  may  have  been  true  at  the  time  Mr.  B.  wrote,  but  it 


FORCEPS.  393 

is  not  now.  On  the  contrary,  cases  are  daily  occurring  of 
tlie  extraction  of  teeth  with  forceps,  upon  which  the  key  had 
heen  previously  unsuccessfully  employed.  It  is  generally 
supposed  that  a  greater  amount  of  force  is  necessary  to  re- 
move a  tooth  with  forceps  than  with  the  key,  but  this  is  a 
mistake.  It  does  not  ordinarily  require  as  much.  All  that 
is  gained  by  the  lever  action  of  the  key,  is  more  than  coun- 
terbalanced by  the  greater  amount  of  resistance  encountered 
in  the  lateral  direction  of  the  force  exerted  by  that  instru- 
ment in  the  removal  of  the  tooth.  But  with  forceps,  the 
direction  of  the  force  being  perpendicular,  either  upwards  or 
downwards,  as  the  tooth  may  be  in  the  upper  or  lower  jaw, 
a  sufficient  amount  only  to  break  up  the  connection  with  the 
socket,  and  to  overcome  the  resistance  of  the  walls  of  the 
alveolus,  is  required. 

The  author  has  used  forceps  exclusively  since  1834,  and 
he  does  not  hesitate  to  affirm,  that  any  tooth  that  can  be  ex- 
tracted with  the  latter,  can  also  be  removed  with  the  former, 
and  that,  too,  in  the  majority  of  cases,  with  greater  ease 
to  the  operator  and  less  pain  to  the  patient.  He  knows  that 
in  this  expression  of  opinion_,  he  differs  from  many  of  his 
professional  brethren  ;  and  that  there  are  many  skillful  and 
experienced  practitioners,  who,  while  they  prefer  forceps  for 
the  extraction  of  most  teeth,  still  occasionally  use  the  key. 
But  he  is  confident,  that,  if  they  would  provide  themselves 
with  forceps  properly  constructed  for  the  extraction  of  the 
various  classes  of  teeth,  which  they  now  remove  with  the 
key,  and  use  tliem  for  six  months,  to  the  exclusion  of  that 
instrument,  they  would  never  employ  it  again. 

It  may  perhaps  require  a  little  more  practice  to  become 
skilled  in  the  use  of  forceps  than  in  that  of  the  key.  We 
would_,  therefore,  advise  those  who  have  been  accustomed  to 
the  key,  not  to  lay  it  at  once  entirely  aside ;  but  to  commence 
the  use  of  forceps  on  teeth  that  are  least  difficult  to  remove, 
as  for  example,  the  bicuspids,  and  afterwards  upon  the 
molars. 

But  in  order  that  forceps  may  be  used  with  ease,  it  is  ne- 
26 


394  FORCEPS. 

cessaiy  they  should  be  of  a  proper  shape  and  construction. 
Every  operator  should  possess  several  pair,  (seven  at  least,) 
each  with  a  differently  shaped  beak,  fitted  to  the  necks  of 
the  teeth  to  ■which  they  are  respectively  designed  to  be  ap- 
plied. 

For  the  extraction  of  molars,  the  forceps  recommended  by 
Mr.  Snell  are  the  best  in  use.  For  the  upper  molars  two 
are  required,  one  for  each  side,  curved  just  below  the  joint, 
80  that  the  jaws  of  the  beak  will  form  an  angle  with  the 
handles,  of  about  twenty  or  twenty-five  degrees,  just  enough 
to  clear  the  lower  teeth.  The  inner  blade  is  grooved  to  fit 
the  palatine  side  of  the  neck  of  one  of  these  teeth  ;  the 
the  outer  blade  has  two  grooves  with  a  point  in  the  centre 
to  fit  the  depression  just  below  the  bifurcation  of  the  two 
buccal  roots. 

Each  blade  of  the  beak  of  the  lower  molar  forceps  has  two 
grooves,  with  a  point  in  the  centre,  so  situated  that  in  grasp- 
ing the  tooth  it  comes  between  the  two  roots  just  at  the  bifur- 
cation. Mr.  Snell  employs  two  pair  for  the  extraction  of 
the  lower,  as  well  as  for  the  upper  molars,  in  order,  as  he 
says,  to  have  a  "hook  to  turn  round  the  little  finger," 
which  he  supposes  must  be  on  opi)osite  sides  of  the  instru- 
ment. But  this  is  rendered  unnecessary  by  an  improve- 
ment made  by  the  author  in  1833,  consisting  in  having  the 
liandles  of  the  instrument  so  bent  that  it  may  be  as  readily 
applied  to  one  side  of  the  mouth  as  tlie  other,  while  the  ope- 
rator occupies  a  position  at  the  right  and  a  little  behind  the 
patient.  By  this  improvement,  the  necessity  for  two  pair 
is  wholly  superseded,  and  it  moreover  enables  him  to  con- 
trol the  head  of  his  patient  with  his  left  arm,  and  the  lower 
jaw  with  his  left  hand,  rendering  the  aid  of  an  assistant 
wholly  unnecessary. 

The  shape  of  the  instrument,  as  improved  by  the  author, 
is  exhibited  in  the  accompanying  engraving,  and  all  who 
use  it  thus  improved,  and  it  is  now  used  by  hundreds,  pre- 
fer it  to  any  other  instrument  they  liave  ever  employed. 
When  applied  to  a  tooth,  the  handles,  as  may  be  perceived. 


FORCEPS. 


395 


turn  toward  the  operator,  forming  an  angle  with  the  median 
line  of  the  mouthy  of  about  twenty-five  or  thirty  degrees. 
Without  this  curvature  in  the  handles,  the  arm  of  the  ope- 
rator would  often  be  thrown  so  far  from  his  body  as  to  pre- 
vent him  from  exercising  the  control  over  it  frequently  re- 
quired in  the  performance  of  the  operation.  And,  while  it 
is  important  that  they  should  be  bent  in  the  manner  here 
represented,  they  should,  at  the  same  time,  be  wide  and 
accurately  fitted  to  the  hand. 

Fig.  126. 


The  improvements  made  by  Mr.  Snell  in  the  shape  of  the 
beaks  of  the  upper  and  lower  molar  forceps,  are  very  valu- 
able, and  for  which  he  is  entitled  to  much  credit — more  than 
the  profession,  generally,  have  accorded.  Another,  and  very 
valuable  improvement  of  his  consists  in  having  one  of  the  han- 
dles bent  so  as  to  form  a  hook.  This  passes  round  the  little 
finger  of  the  operator's  hand,  to  prevent  it  from  slipping. 
In  the  drawings  which  Mr.  Snell  has  given  of  his  superior 
molar  forceps,,  the  hook  is  on  the  palatine  handle  of  each, 
so  that  in  the  extraction  of  a  right  upper  molar,  the  upper 
side  of  the  instrument  must  be  grasped,  and  the  lower  side 
in  the  extraction  of  a  left  upper  molar.  But  the  author  has 
found  that  by  having  the  handle  so  bent,  tliat  when  applied 
the  hook  of  each  is  next  tiie  operator,  they  can  be  more  con- 
veniently employed  ;  and,  as  in  the  case  of  the  lower  molar 
forceps,  tlie  handles  should  be  wide,  and  large  enough  to 
prevent  them  from  springing  under  the  grasp  of  his  hand ; 


396 


FORCEPS. 


to  which,  too,  they  should  be  accurately  fitted.  The  beak 
should  be  bent  no  more  than  is  absolutely  necessary  to  pre- 
vent the  handles  from  coming  in  contact  with  the  teeth  of 
the  lower  jaw  ;  for  in  proportion  to  the  greatness  of  the  cur- 
vature will  the  force  required  to  be  applied  to  the  instru- 
ment, be  disadvantageously  exerted.  Every  dentist,  there- 
fore, in  having  forceps  manufactured,  should  give  special 
directions  with  regard  to  their  shape  and  size.  For  the  ex- 
traction of  the  superior  molars,  two  forceps,  as  has  been 
before  stated,  are  necessary  ;  one  for  the  right  and  one 
for  the  left  side,  as  represented  in  Fig.  127. 

FiQ.  127. 


For  the  extraction  of  the  upper  incisors  and  cuspids,  one 
pair  only  is  necessary.  These  should  be  straight,  with 
grooved  or  crescent-shaped  jaws,  accurately  fitted  to  the 
necks  of  the  teeth.  They  should  also  be  thin,  so  that  when 
it  becomes  necessary,  from  the  decay  of  the  tooth,  they  may 
be  easily  introduced  under  the  gum,  up  to  the  edge  of  the 
alveolus.     And,  like  the  superior  and  inferior  molar  forceps, 


FORCEPS. 


397 


the  handles  should  be  large  enough  to  prevent  them  from 
springing  in  the  hand  of  the  operator,  and  a  hook  formed  at 
the  end  of  one  of  them. 


Fia.  128. 


For  the  extraction  of  the  lower  incisors,  a  pair  of  very- 
narrow  beaked  forceps  are  necessary,  to  prevent  interfering 
with  the  teeth  adjoining  the  one  to  be  removed.  The  beak 
below  the  joint  of  the  instrument,  should  be  bent  downward 
so  as  to  form  an  angle  of  about  twenty-five  degrees  with 
the  handles,  (Fig.  129.)  This,  too,  is  one  of  the  most  use- 
ful instruments  that  can  be  employed  for  the  extraction  of 
roots  of  teeth. 

Fig.    129. 


Forceps  for  the  extraction  of  the  bicuspids  should  have 
their  jaws  so  bent  as  to  be  easily  adapted  to  these  teeth ; 
they  should  be  narrow  and  have  a  deeper  groove  on  the  in_ 
side  than  those  for  the  upper  incisors  and  cuspidati,  and  like 
them  should  be  thin,  yet  strong  enough  to  sustain  the  pres- 
sure which  it  may  be  necessary  to  apply.  One  pair  will 
answer  for  the  bicuspids  of  both  jaws,  but  when  only  one 
pair  is  employed,  both  handles  must  be  straight.  The  en- 
graving, Fig.  130,  represents  the  instrument  here  described. 


398 


FORCEPS. 


I 


For  the  removal  of  the  cuspids  of  the  lower  jaw,  the 
hawk's-hill  forceps,  with  crescent-shaped  beaks,  are  often  em- 
ployed, but  the  instrument  last  described,  and  represented 
in  Fig.  130,  is  better  suited  to  the  extraction  of  these  teeth, 
and  can  be  more  conveniently  applied  and  used  than  the 
other.  No  other  instrument  is  required  for  the  removal  of 
the  inferior  cuspids. 

Fig.  130. 


The  dentes  sapienti^e  in  a  large  majority  of  cases,,  can  be  as 
readily  extracted  with  the  bicuspid  forceps,  as  any  other, 
and  those  can  be  as  conveniently  applied  to  the  teeth  of  the 
upper  as  to  those  of  the  lower  jaw. 

But  there  is  another  kind  of  forceps,  which  can  be  em- 
ployed for  the  removal  of  the  upper  dentes  sapientiee,  when 
the  bicuspid  forceps  cannot  be  applied.     The   beak  of  these 

Fig.  131. 


is  bent  above  the  joint,  forming  nearly  two  right  angles,  as 
shown  in  Fig.  131.  These  forceps^  we  believe,  were  invent- 
ed by  the  late  Dr.  Edward  P.  Church,  about  the  year  1830, 
and  in  those  cases  where  the   superior  dentes  sapientiee  are 


MANNER   OF   USING   THE   KEY   INSTRUMENT.  399 

considerably  shorter  than  the  second  molars,  they  can  be 
successfully  and  advantageously  employed,  and  often  times 
when  they  cannot  be  reached  with  any  other  extracting  in- 
strument.* These  forceps  are  also  useful  in  the  extraction 
of  roots  of  teeth,  situated  behind  a  bicuspid  or  molar  tooth 
which  has  a  very  long  crown. 

A  great  variety  of  forceps  and  other  instruments  have 
been  invented  and  used  for  the  extraction  of  teeth  ;  butthe 
author  has  not  seen  any  comparable  with  those  which  he 
has  just  described.  Seven  pair  are  all  that  are  really  neces- 
sary ;  and  these,  if  properly  constructed,  are  better  and 
more  efficient  than  thirty  pair  of  the  awkwardly  contrived 
forceps  which  many  dentists  use. 

The  handles  of  a  pair  of  forceps  should  be  no  longer  than 
is  absolutely  necessary  for  the  accommodation  of  the  hand 
of  the  operator. 

MANNER  OF  USING  THE  KEY  INSTRUMENT. 

The  directions  required  for  the  use  of  the  key  are  few  and 
simple  ;  but,  as  cases  frequently  present  themselves  to  which 
no  general  rules  can  be  applied,  much  will  depend  on  the 
practical  judgment  and  surgical  tact  of  the  operator.  The 
first  step  to  be  taken  in  the  operation,  is,  to  separate  the 
gum  from  the  neck  of  the  tooth  down  to  the  alveolus,  and 
this  should  be  done,  not  only  on  two  sides,  but  all  round. 
For  this  purpose,  suitable  knives  should  be  provided.  On 
the  approximal  sides  of  the  tooth,  a  straight,  narrow- 
bladed  knife,  pointed  at  the  end,  and  with  one  cutting  edge, 
will  be  found  most  convenient  and  efficient,  in  performing 

*  Dr.  Church  was  an  ingenious  and  talented  man,  and  during  his  brief  profes- 
sional career — a  period  of  about  four  years,  he  acquired  a  reputation  for  skill, 
which  but  few,  in  so  short  a  time,  have  ever  been  able  to  achieve,  and  had  his  life 
been  spared,  he  v.'ould  soon  have  ranked  among  the  very  first  practitioners  in  the 
country.  Born  in  the  western  part  of  the  state  of  New  York,  he  chose  the  Missis- 
sippi Valley  as  a  temporary  field  for  his  professional  labors,  intending  altiraately 
to  locate  in  Cincinnati,  but  during  the  prevalence  of  the  Asiatic  cholera,  in  1832, 
he  fell  a  victim  to  this  ruthless  destroyer,  while  on  a  visit  to  his  family,  in  New 
York,  in  the  26th  or  27th  year  of  his  age. 


400  MANNER   OF    USING   THE   KEY   INSTRUMENT. 

this  part  of  the  operation  ;  and  it  may  he  most  effectively 
used,  by  passing  the  point  between  the  neck  of  the  tooth 
and  gum,  down  to  the  alveolus,  with  the  back  downwards, 
cutting  from  the  direction  of  the  root  towards  the  coronal 
extremity  of  the  tooth.  In  this  way,  the  connection  of  the 
gum  to  the  sides  of  the  neck  of  the  tooth  may  be  thorough- 
ly severed.  The  same  kind  of  knife  or  a  common  gum- 
lancet,  may  be  used  for  separating  the  gum  from  the  lin- 
gual or  palatine,  and  buccal  sides  of  the  tooth.  If  this 
precaution  be  neglected,  there  will  be  danger  of  lacerating 
it  in  the  removal  of  the  tooth. 

After  the  tooth  has  been  thus  prejjared,  the  key,  with 
the  proper  hook  attached,  should  be  firmly  fixed  upon  it ; 
the  fulcrum,  on  the  inside,  resting  upon  the  edge  of  the  al- 
veolus, the  extremity  of  the  claw  on  the  opposite  side, 
pressed  down  upon  the  neck.  The  handle  of  the  instru- 
ment is  grasped  with  the  right  hand,  and  the  tooth,  by  a 
firm,  steady  rotation  of  the  wrist,  raised  from  its  socket. 
The  claw  should  be  pressed  down  with  the  fore-finger  or 
thumb  of  the  left  hand  of  the  operator,  until,  by  the  rota- 
tion of  the  instrument,  it  becomes  securely  fixed  to  the 
tooth.  Tliis  precaution  is  necessary  to  prevent  it  from  slip- 
ping— an  accident  ttlat  frequently  happens,  and  one  that  is 
always  more  or  lef.6  embarrassing  to  the  dentist. 

If  the  tooth  is  fiituated  on  the  left  side  of  the  mouth,  the 
position  of  the  qfperator  should  be  at  the  right  side  of  the 
patient ;  but,  ir  it  be  on  the  right  side,  he  should  stand  be- 
fore him.  ^--^ 

For  t]ief  removal  of  a  tooth,  on  the  left  side  of  the  lower 
jaw,  or  xhe  right  side  in  the  upper,  the  palm  of  the  hand 
should  be  beneath  the  handle  of  the  instrument ;  and  vice 
versa,  in  the  extraction  of  one  on  the  right  side  of  the  lower 
jaw,  or  on  the  left  side  in  the  upper.  The  manner  of  grasp- 
ing the  instrument,  is,  perhaps,  of  more  importance  than 
many  imagine.  If  taken  hold  of  improperly,  the  operator 
loses,  to  a  great  extent,  his  control  over  it. 

The  directions  here  given,  are,  in  some  respects,  different 


MANNER   OF   USING  THE   FORCEPS.  401 

from  those  laid  clown  by  other  writers  ;  yet,  we  are  con- 
vinced, from  much  experience,  that  they  will  be  found  more 
conducive  to  the  convenience  of  the  operator  and  the  suc- 
cess of  the  operation  than  those  usually  given  for  the  use  of 
this  instrument. 

There  is  a  great  diversity  of  opinion_,  as  to  whether  a 
tooth  should  be  removed  inwards  or  outwards.  Some  di- 
rect the  fulcrum  of  the  instrument  to  be  j)laced  on  the  out- 
side of  the  tooth,  others  on  the  inside,  while  others  again, 
regard  it  as  of  little  importance  on  which  side  it  is  placed. 
But  experience  has  taught  us  that  it  should,  in  the  majority 
of  cases,  be  placed  on  the  inside,  especially  of  the  lower 
teeth,  as  they  almost  always  incline  towards  the  interior  of 
the  mouth.  Moreover,  the  edge  of  the  alveolus  is  usually 
a  little  higher  on  the  exterior  edge  of  the  jaw  than  on  the 
interior  ;  so,  that  the  first  motion  of  the  instrument^  with 
its  fulcrum  on  the  outside,  brings  the  side  of  the  tooth 
against  its  socket,  and  thus,  nearly  double  the  amount  of 
power  is  required  to  remove  it ;  while,  at  the  same  time, 
the  pain  and  the  chances  of  injury  to  the  alveolar  processes 
are  very  much  incrcised. 

The  alveolar  walls  of  the  upper  teeth  are,  generally, 
thinner  than  those  of  the  lower,  and  do  not  afford  so  strong 
a  support  to  the  fulcrum  of  the  instrument. 

It  is,  however,  frequently  necessary  to  place  the  bolster  of 
the  instrument  on  the  outside  of  the  tooth  ;  especially  when 
it  is  decayed  in  such  a  way,  as  not  to  afford  a  sufficiently 
firm  support  for  the  claw  of  the  instrument.  Biit^  when- 
ever it  is  possible  to  remove  a  tooth  inwards,  it  should  be 
done. 

MANNER  OP  USING  THE  FORCEPS. 

In  describing  the  manner  of  using  these  instruments,  we 
shall  commence  with  the  extraction  of  the  incisors  of  the 
upper  jaw.  These  are  generally  more  easily  removed  than 
any  of  the  other  teeth. 


402  MANNER   OF   USING   THE   FORCEPS. 

After  separating  the  gum  from  the  neck  of  the  tooth,  the 
latter  may  be  grasped  with  a  pair  of  straight  forceps,  like 
those  represented  in  Fig.  128,  and  pressed  several  times,  in 
quick  succession,  outwards  and  inwards,  giving  it  at  the 
same  time,  a  slight  rotary  motion,  which  should  be  contin- 
ued until  it  begins  to  give  way  ;  when,  by  a  slight  pull 
downwards,  it  is  easily  removed. 

If  the  tooth  is  much  decayed,  it  should  be  grasped  as 
high  up  under  the  gum  as  possible,  and  no  more  pressure 
applied  to  the  handles  of  the  instrument  than  may  be  ne- 
cessary to  prevent  it  from  slipping.  Teeth  are  often  unne- 
cessarily broken  by  not  attending  to  this  precaution. 

The  same  directions  will,  in  most  cases,  be  found  appli- 
cable for  the  removal  of  a  lower  incisor.  But  the  arrange- 
ment of  these  teeth  are  sometimes  such  as  to  render  their 
extraction  rather  more  difficult.  The  forceps  best  calcu- 
lated for  the  removal  of  these  are  represented  in  Fig.  129. 

For  the  extraction  of  a  cuspidatus^  greater  force  is  usu- 
ally required,  than  for  the  removal  of  an  incisor.  The 
straight  forceps  (see  Fig.  128)  should  be  employed  for  the 
removal  of  the  superior,  and  curved-beaked  forceps,  (see 
Fig.  130)  for  the  inferior  cuspids.  But  in  the  extraction  of 
one  of  these  teeth,  less  rotary  motion  should  be  given  to  the 
hand  than  in  the  removal  of  a  tooth  situated  in  the  front  of 
the  mouth.  In  every  other  respect^  the  operation  is  con- 
ducted in  the  same  manner.  The  inferior  cuspids  usually 
have  longer  roots,  and  are,  as  a  general  thing,  more  diffi- 
cult to  remove  than  the  superior. 

Very  little  rotary  motion  can  be  given  to  a  biscuspid,  es- 
pecially an  upper,  in  its  extraction.  After  it  has  been 
pressed  outwards  and  inwards  several  times,  or  until  it  be- 
gins to  give  way,  it  should  be  removed  by  depressing  or 
elevating  the  hand,  as  it  may  happen  to  be  in  the  upper  or 
lower  jaw  ;  but  for  the  extraction  of  the  upper^  the  forceps 
represented  in  Fig,  128,  and  for  the  lower,  those  represent- 
ed in  Fig.  130,  are  the  proper  instruments  to  be  employed, 
except  the  crown  has  become  so  much  weakened  by  decay, 


MANNER   OF   USING   THE  FORCEPS.  403 

that  it  will  not  bear  the  requisite  amount  of  pressure.  In 
this  case,  the  gum  should  be  separated  on  each  side  from 
the  alveolus,  about  an  eighth  or  three-sixteenths  of  an  inch 
above  its  margin,  and  slitted  so  as  to  admit  of  the  applica- 
tion of  the  narrow-beaked  forceps,  Fig.  129.  With  these, 
the  alveolar  wall  on  each  side,  may  be  easily  cut  through, 
and  a  sufficiently  firm  hold  obtained  upon  the  root  of  the 
tooth,  for  its  removal.  These  forceps  will  also  be  found 
better  adapted  for  the  removal  of  any  of  the  back  teeth  or 
cuspids,  when  in  a  similar  condition,  than  any  other  instru- 
ment. 

The  upper  molars,  having  three  roots,  generally  require 
a  greater  amount  of  force  for  their  removal  than  any  of  the 
other  teeth.  They  should  be  grasped  as  high  up  as  possi- 
ble, with  one  of  the  forceps  represented  in  Fig.  127,  and 
then  pressed  outwards  and  inwards,  until  the  tooth  is  well 
loosened^  when  it  may  be  pulled  from  the  socket.  If  the 
forceps  used  for  the  extraction  of  the  upper  molars  are  of 
the  right  description,  and  properly  applied,  they  will  be 
found  the  safest  and  most  efficient  instruments  that  can  be 
employed  for  their  removal. 

The  superior  dentes  sapientise  are  usually  less  firmly  ar- 
ticulated to  the  jaw  than  are  the  first  and  second  molars, 
and  are,  therefore,  more  easily  removed  than  either  of  the 
last  mentioned  teeth.  When  their  crowns  are  sufficiently 
long  to  admit  of  being  grasped  with  the  bicuspid  forceps, 
(see  Fig.  130,)  they  should  be  removed  with  this  instru- 
ment, but  when  this  cannot  be  applied  without  interfering 
with  the  anterior  teeth,  the  forceps  represented  in  Fig.  131, 
may  be  substituted. 

The  inferior  molars,  although  they  have  but  two  roots, 
are  often  very  firmly  articulated,  and  require  considerable 
force  for  their  removal,  and  it  sometimes  happens,  that 
when  the  approximal  side  of  one  has  been  destroyed  by 
caries,  the  adjoining  tooth  has  impinged  upon  it  in  such  a 
manner  as  to  constitute  a  formidable  obstacle  to  its  extrac- 


404  MANNER   OF   USING   THE  FORCEPS. 

tion.  Two  teetli  are  often  removed  in  attempting  to  ex- 
tract one  when  thus  situated,  if  the  precaution  of  filling 
the  side  of  the  encroaching  tooth  has  not  been  previously 
used.  This  should  never  be  omitted  in  the  extraction  of  a 
lower  molar  or  bicuspid,  locked  in  the  manner  just  de- 
scribed. And,  though  less  frequently,  it  sometimes  hap- 
pens that  the  upper  teeth  impinge  upon  each  other  in  the 
same  manner,  and  when  this  occurs,  the  adjoining  tooth 
should  be  filed  sufficiently  to  liberate  the  one  that  is  to 
be  extracted,  before  attempting  its  removal.  In  applying 
forceps  to  an  inferior  molar,  the  points  on  the  ends 
of  the  beak  of  the  instrument  should  be  forced  down 
between  the  roots,  and  after  having  obtained  a  firm  hold^ 
the  tooth  should  be  forced  outwards  and  inwards  several 
times  in  quick  succession,  until  its  connection  with  the  jaw 
is  partially  broken  up,  and  then  raised  from  the  socket.  If 
the  tooth  has  decayed  down  to  the  neck,  the  upper  edge  of 
the  alveolus  may  be  included  between  the  points  of  the  beak 
through  which  they  will  readily  pass,  on  applying  pressure 
to  the  handles,  and  in  this  manner  a  secure  hold  will  be  ob- 
tained upon  the  tooth.  The  same  should  also  be  done  in 
the  extraction  of  a  superior  molar  in  this  condition. 

The  dentes  sapientire  in  the  lower  jaw,  when  situated  far 
back  under  the  coronoid  processes,  are  oftentimes  exceed- 
ingly diflicult  to  extract,  but  with  forceps  like  those  repre- 
sented in  Fig.  129,  they  may  always  be  grasped,  by  a  little 
tact  on  the  part  of  the  operator,  except  in  those  cases  where 
their  crowns  have  been  destroyed  by  caries,  when  a  portion 
of  the  alveoli  should  be  cut  away^  either  with  forceps,  or  a 
strong  sharp-pointed  instrument,  previous  to  attempting 
their  removal.  It  occasionally  happens,  too,  that  the  roots 
of  these  teeth  are  bent  in  such  a  manner  as  to  constitute  a 
considerable  obstacle  to  their  removal.  But  when  this  is 
the  case,  the  roots  are  almost  always  turned  posteriorly 
towards  the  coronoid  processes,  so  that  after  starting  the 
tooth,  if  the  operator  is  unable  to  lift  it  perpendicularly 
from  the  socket,  he  will  have  reason  to  suspect  its  retention 


MANNER   OF   EXTRACTING   ROOTS   OF   TEETH.  405 

to  be  owing  to  an  obstacle  of  this  nature.  To  overcome 
this,  as  he  raises  his  hand,  he  shoiikl  push  the  crown  of  the 
tooth  backwards,  making  it  describe  the  segment  of  a  cir- 
cle ;  for  should  he  persist  in  his  efforts  to  remove  it  directly 
upwards_,  the  root  wiU  be  broken  and  left  in  the  jaw. 

It  sometimes  happens,  too,  that  the  roots  of  the  first  and 
second  molars  of  both  jaws,  and  those  of  the  superior  dentes 
sapientiee,  are  bent,  or  diverge,  or  converge  so  much  as  to 
render  their  extraction  exceediugl}^  difficult.  The  conver- 
gency  of  these  is  often  so  great,  that  in  their  removal,  the 
intervening  wall  of  the  alveolus  is  brought  away,  but 
neither  from  this,  nor  from  the  removal  of  a  portion  of  the 
exterior  wall,  will  any  unpleasant  effects  result.  Similar 
malconformations  are  occasionally  met  with  in  the  roots  of 
the  bicuspids,  the  cuspidati^  and  even  the  incisor  teeth. 

Other  obstacles  sometimes  present  themselves  in  the  ex- 
traction of  teeth,  which  the  judgment  and  tact  of  the  opera- 
tor alone  will  enable  him  to  overcome.  The  nature  and 
peculiarity  of  each  case  will  suggest  the  method  of  procedure 
most  proper  to  be  pursued.  The  dentist  should  never  hesi- 
tate, when  necessary  to  enable  him  to  obtain  a  firm  hold 
upon  the  tooth,  to  embrace  a  portion  of  the  alveolus 
between  the  jaws  of  the  forceps.  The  removal  of  the  upper 
edge  of  the  socket  is  never  productive  of  injury,  as  it  is 
always,  soon  after  the  extraction  of  the  tooth,  destroyed 
by  a  peculiar  operation  of  the  economy.  By  this  means, 
when  the  crown  of  a  tooth  has  become  so  much  weakened 
by  disease  that  it  will  not  bear  the  pressure  of  the  instru- 
ment, it  may  be  removed ;  and  without  inflicting  upon  the 
patient  half  the  pain  that  would  otherwise  be  caused  by  the 
operation. 

MANNER  OF   EXTRACTING   ROOTS   OP   TEETH.       ' 

The  extraction  of  roots  of  teeth  is  sometimes  attended 
with  considerable  difficulty ;  but,  generally,  they  are  more 
easily  removed  than  whole   teeth,  and  especially  those  of 


406 


MANNER   OF  EXTRACTING   ROOTS  OF  TEETH. 


the  molars,  for  after  the  destruction  of  their  crowns,  an 
effort  is  usually  made  by  the  economy  to  expel  them  from 
the  jaws,  consisting  in  the  gradual  destruction  and  filling 
up  of  the  socket,  by  a  deposition  of  ossific  matter  at  the  bot- 
tom, whereby  the  articulation  of  the  root  becomes  weakened 
and  its  removal  rendered  proportionately  easier.  The  al- 
veolar cavities  are  often  wholly  obliterated  in  the  course  of 
two  or  three  years  after  the  destruction  of  the  crowns  of  the 
teeth,  and  the  roots  retained  in  the  mouth,  simply  by  their 
connection  with  the  gums,  so  that  for  their  removal,  little 
more  is  necessary  than  to  sever  this  bond  of  union  with  a 
lancet  or  sharp-pointed  knife. 

Fig.  132. 


Fig.  133. 


The  instruments  usually  employed  in  the  extraction  of 
roots  of  teeth,  are  the  hook,  punch,  elevator  and  screw  ;  all 
of  which  are  represented  in  Figs.  132  and  133.  Although 
every  dentist  has  them  made  to  suit  his  oAvn  peculiar 
notions,  the  manner  of  using  them,  and  the  principle 
upon  which  they  act,  are  the  same.  It  will,  therefore,  be 
sufficient  to  say,  that  they  should  be  of  a  convenient  size, 


MANNER   OF  EXTRACTING   ROOTS   OF   TEETH.  407 

made  of  good  steel,  and  so  tempered  as  neither  to  bend  nor 
break. 

The  hook  a,  Fig.  132,  is  chiefly  used  for  the  extraction 
of  the  roots  of  the  molar  and  bicuspid  teeth  on  the  left  side 
of  the  mouth;  the  punch  &,  Fig.  132,  for  the  removal  of 
roots  on  the  right  side;  the  elevator  c,  Fig.  133,  for  the  ex- 
traction of  roots  on  either  side,  as  occasion  may  require; 
and  the  screw  d,  Fig.  133,  for  the  removal  of  the  upper 
front  teeth. 

Considerable  tact  is  necessary  for  the  skillful  use  of  these 
instruments,  and  this  can  only  be  obtained  by  practice. 
Great  care  is  requisite  in  using  the  punch  and  elevator,  to 
prevent  them  from  slipping  and  injuring  the  mouth  of  the 
patient.  Whenever,  therefore,  either  of  these  are  used,  the 
fore-finger  of  the  left  hand  of  the  operator  should  be  wrap- 
ped with  a  cotton  or  linen  rag,  and  placed  on  the  side  of  the 
root  opposite  to  that  against  which  the  instrument  is  aj)plied, 
so  as  to  catch  the  point  in  case  it  should  slij). 

But,  for  the  removal  of  the  roots  of  bicuspids  and  molars, 
and  often  for  those  of  the  cuspids  and  incisors,  the  narrow 
beaked  forceps,  recommended  for  the  extraction  of  the  lower 
incisors,  (see  Fig.  129,)  may  be  used  more  efficiently  than 
any  other  instrument.  When  the  root  is  decayed  down  to 
the  alveolus,  the  gum  should  be  separated  from  the  latter_, 
and  so  much  of  it  as  may  be  necessary  to  obtain  a  secure 
hold  upon  the  former,  included  between  the  jaws  of  the  beak 
of  the  forceps,  which,  from  their  being  very  narrow,  readily 
pass  through  it,  and  a  firm  hold  is  at  once  obtained  upon 
the  root;  when,  after  moving  it  a  few  times,  outwards  and 
inwards,  it  may  easily  be  removed  from  its  socket.  There 
are  some  cases,  however,  in  which  the  punch,  hook  and 
elevator  may  be  advantageously  used.  We  have  also  occa- 
sionally met  with  cases  where  we  have  succeeded  in  remov- 
ing roots  of  teeth  with  great  ease,  with  an  elevator  shaped 
like  the  blade  of  a  knife,  by  forcing  it  into  the  socket  by  the 
side  of  the  root,  and  then  turning  it  so  as  to  make  the  back 
press  against  the  former,  and  the  edge  against  the  latter. 


408 


MANNER   OF   EXTRACTING  ROOTS   OF  TEETH. 


When  this  instrument,  winch  is  represented  in  Fig.  134,  is 
used,  the  blade  should  not  be  more  than  an  inch  in  length, 
and  it  should  be  straight,  short  at  the  point,  and  have  a 
very  thick  back,  in  order  to  prevent  breaking  in  the  opera- 
tion.    In  using  the  common  elevator,  it  is  necessary  that 

Fig.  134. 


there  should  be  an  adjoining  tooth  or  root,  to  act  as  a 
fulcrum.  When  this  can  be  employed,  a  root,  or  even  a 
whole  tooth,  may  sometimes  be  removed  with  it;  but  as  a 
general  rule,  forceps  should  be  preferred  to  any  of  these 
instruments. 

For  the  extraction  of  the  roots  of  the  upper  front  teeth, 
after  they  have  become  so  much  funneled  out  by  decay  as 
to  render  their  walls  incapable  of  sustaining  the  pressure  of 
forceps,  the  conical  screw  is  invaluable.  With  this  a  suffi- 
ciently firm  hold  can  be  obtained  by  screwing  it  into  the 
cavity  for  the  removal  of  the  root.  But  before  it  is  intro- 
duced the  softened  decomposed  dentine  should  be  removed 
from  the  interior  of  the  root,  with  a  triangular  pointed  in- 
strument like  the  one  represented  in  Fig.  135. 

Fig.  135. 


Dr.  S.  P.  HuUihen  invented  a  most  valuable  and  use- 
ful instrument  for  the  removal  of  the  roots  of  the  superior 
incisors  and  cuspids  in  the  condition  just  described.  It  com- 
bines the  advantages  both  of  the  screw  and  forceps,  as  may 
be  seen  by  the  accompanying  cut.  It  is  thus  described  by 
the  author  :  '^'Lengthwise,  within  and  between  the  blades  of 
the  beak,  is  a  steel  tube,  one  end  of  which  is  open  ;  the  other 
solid  and  flat,  and  jointed  in  a  mortice  in  the  male  part  of 


MANNER   OF   EXTRACTING  ROOTS   OF   TEETH. 


409 


the  joint  of  the  forceps.  When  the  forceps  are  opened,  this 
joint  permits  the  tuhe  to  fall  hackwards  and  forwards  from 
one  blade  of  the  beak  to  the  other,  without  any  lateral 
motion.  Within  this  tube  is  a  spiral  spring,  which  forces 
up  a  shaft  two-thirds  of  the  tube,  the  other  part  is  a  well 
tapered  or  conical  screw.  *  *  *  *  The  shaft  and  tube  are 
so  fitted  together,  and  to  the  beak  of  the  forceps,  that  one- 
half  of  the  rounded  part  of  the  shaft  projects  beyond  the 
end  of  the  tube  ;  so  that  the  shaft  may  play  up  and  down 
upon  the  spring"  about  half  an  inch,  and  the  screw  or 
shaft  be  embraced  between  the  blades  of  the  beak  of  the 

instrument . 

Fia.  136. 


The  instrument  here  represented,  (see  Fig.  136,)  differs  a 
little  from  Dr.  Hullihen's,  in  the  manner  of  its  construction, 
thoiigh  it  acts  upon  precisely  the  same  principle. 

''The  forceps,"  says  Dr.  H.^  "are  used  by  first  embracing 
the  shaft  between  the  blades."*  "Then  screwing  it  as 
gently  and  deeply  into  the  root  as  possible,  the  blades  are 
opened — pushed  up  on  the  root,  which  is  then  seized"  and 
extracted. 

"The  screw  thus  combined  with  the  forceps,  prevents  the 
root  from  being  crushed.  It  acts  as  a  powerful  lever  when 
a  lateral  motion  is  given ;  it  is  likewise  of  advantage  when 

*  The  author  has  a  pair  constructed  so  that  the  upper  extremity  of  the  screw  is 
grasped  between  the  blades  of  the  beak  of  the  forceps  instead  of  the  shaft. 

27 


410 


MANNER  OF    EXTRACTINa   ROOTS   OF  TEETH. 


a  rotary  motion  is  made — it  prevents  the  forceps  from  slip- 
ping, or  of  their  action  being  lost,  should  even  one  side  of 
the  root  give  way  in  the  act  of  extracting  it — and  is  used 
with  equal  advantage  where  one  side  of  the  root  is  entirely 
gone." 

The  opportunities  which  the  author  has  had  of  testing  the 
value  of  this  instrument,  have  been  sufficient  to  justify  him 
in  stating  that  its  merits  are  not  overrated  by  the  inventor. 
Every  practitioner  would,  therefore,  do  well  to  provide  him- 
self with  one  of  them. 

Fig.  137. 


For  the  extraction  of  the  roots  of  the  upper  molars,  be- 
fore they  have  become  separated  from  each  other,  the  forceps 
represented  in  Fig.  137,  invented  by  Dr.  Maynard,  will  be 
found  highly  valuable.  The  outer  nib  of  each  instrument 
is  brought  to  a  sharp  point,  for  perforating  the  alveolus  be- 
tween the  buccal  roots,  and  for  securing  between  them  a  firm 
hold,  while  the  inner  nib  is  intended  to  rest  upon  the  edge  of 
the  alveolus  and  embrace  the  palatine  fang.  By  this  means 
a  sufficiently  firm  hold  is  secured  to  enable  the  operator  to 
remove  the  roots  of  an  upper  molar  without  difficulty  ;  two 
pair,  as  represented  in  the  engraving,  one  for  the  right  and 


HEMORRHAGE   AFTER  EXTRACTION.  411 

one  for  the  left  side,  are  required.  The  advantage  to  be 
derived  from  forceps  of  this  description,  must  be  apparent 
to  every  dentist. 

EXTRACTION  OF  THE  TEMPORARY  TEETH. 

The  temporary  teeth  should  be  extracted  in  the  same 
manner  as  the  permanent,  and  with  the  same  instru- 
ments. If  the  power  be  properly  directed,  very  little  force 
is  required  for  their  removal,  because  the  roots  of  these  teeth 
have  generally  suffered  more  or  less  loss  of  substance  before 
the  operation  is  called  for,  and  when  they  remain,  the  alve- 
olar processes,  at  this  early  age,  are  so  soft  and  yielding  as 
to  offer  little  resistance  to  the  tooth. 

The  operator  should  be  careful  not  to  injure  the  pulps  of 
the  permanent  teeth,  or  the  jaw  bone.  Serious  accidents 
sometimes  occur  from  an  improper  or  awkward  removal  of 
these  teeth.  But,  as  has  been  before  remarked,  their  extrac- 
tion is  seldom  required.  It  should  only  be  resorted  to  for 
the  relief  of  tooth-ache,  the  cure  of  alveolar  abscess,  to  pre- 
vent irregularity  in  the  permanent  teeth,  or  in  case  of  ne- 
crosis of  the  socket. 

HEMORRHAGE  AFTER  EXTRACTION. 

It  rarely  happens  that  excessive  hemorrhage  follows  the 
extraction  of  a  tooth.  Indeed,  it  is  oftener  more  desirable 
to  promote  bleeding  by  rinsing  the  mouth  with  warm  water 
than  to  attempt  its  suppression.  Nevertheless,  cases  do 
sometimes  occur  in  which  it  becomes  excessive  and  alarming  ; 
and  it  has  been  known,  in  some  instances,  to  terminate 
fatally. 

Excessive  hemorrhage,  however_,  does  not  appear  to  be 
dependent  upon  the  manner  in  which  the  operation  is  per- 
formed, but  rather  upon  a  hemorrhagic  diathesis  of  body. 
Hence,  whenever  a  tendency  to  it  exhibits  itself  in  one  mem- 
ber of  a  family,  it  is  usually  found  to  exist  in  all.     Of  the 


412  HEMORRHAGE   AFTER   EXTRACTION. 

many  cases  whicli  have  fallen  under  onr  own  observation, 
we  shall  mention  only  one. 

In   the  fall  of  1834,  Miss  I ,  a  yonng  lady  of  about 

fifteen  years  of  age,  called  on  us  to  have  the  second  molar 
on  the  left  side  of  the  upper  jaw  removed.  The  hemorrhage 
immediately  after  the  operation,  was  not  greater  than  usu- 
sually  occurs^  and  in  the  course  of  half  or  three-quarters  of 
an  hour,  it  ceased  altogether.  But  at  about  twelve  o'clock 
on  the  following  night,  it  commenced  again,  the  blood  flow- 
ing so  i^rofusely  as  to  excite  considerable  alarm.  A  mes- 
senger was  immediately  sent  to  ask  our  advice,  and  we  di- 
rected that  the  alveolar  cavities  be  filled  with  pledgets  of 
lint,  saturated  with  tinct.  of  nut  galls.  Two  days  after,  at 
about  six  o'clock  in  the  morning,  we  were  hastily  sent  for 
by  the  young  lady's  mother,  and  when  we  arrived  at  her 
residence,  were  informed  that  the  bleeding  had  then  been 
going  on  for  about  four  hours.  During  this  time  more  than 
two  quarts  of  blood  had  been  discharged.  The  blood  was 
still  oozing  very  fast.  After  we  had  removed  the  coagulum, 
we  filled  the  alveolus  with  pieces  of  sponge,  saturated,  as 
the  lint  had  been,  with  tinct.  of  nut  galls.  When  firmly 
pressed  in,  and  secured  by  a  compress,  the  hemorrhage 
ceased.  These  were  permitted  to  remain  until  they  were 
expelled  by  the  suppurative  and  granulative  processes. 

We  afterwards  had  occasion  to  extract  a  tooth  for  a  sister 
and  two  for  the  mother  of  the  young  lady,  and  a  hemorr- 
hage, similar  to  that  just  described,  occurred  in  each  case. 

We  have  had^  perliaf)s,  some  thirty  or  forty  cases  of  this 
description,  but  never  found  it  necessary,  except  in  one  in- 
stance, to  adopt  any  other  course  of  treatment  than  that  de- 
scribed in  the  case  just  narrated.  More  powerful  remedies, 
however,  are  sometimes  employed.  Some  use  a  solution  of 
the  sul.  cupri,  or  of  the  nitrate  of  silver,  while  others  em- 
ploy the  actual  cautery.  But  if  pressure  be  so  applied  as  to 
act  directly  upon  the  mouths  of  the  bleeding  vessels,  it  will 
almost  always  arrest  the  hemorrhage.     The  author  has,  in 


I 


HEMORRHAGE   AFTER   EXTRACTION.  413 

two  oases,  found  it  necessary  to  have  recourse  to  the  actual 
cautery. 

The  following  case  is  quoted  by  Dr.  Fitch,  from  Le  Den- 
tiste  Ohservateur,  par  H.  G.  Coiaiois,  Paris,  1775. 

"A  person  living  in  Paris,  called  on  me  to  extract  a  ca- 
nine tooth  for  him.  On  examining  his  mouth,  I  thought 
that  this  man  was  attacked  with  scurvy  ;  but  this  did  not 
seem  suflScient  to  hinder  the  person  from  having  his  tooth 
extracted,  much  less  would  he  have  consented  to  it  on  ac- 
count of  the  pain  which  his  tooth  gave  him.  After  the  tooth 
was  extracted,  it  did  not  appear  to  me  that  it  bled  more 
profusely  than  is  customary  after  similar  operations.  In  the 
meanwhile,  the  following  night  I  was  called  upon  to  see  the 
patientj  who  had  continued  to  bleed  ever  since  he  left  me. 
I  employed,  for  stopping  this  hemorrhage,  the  agaric  of  the 
oak  bark,  which  I  commonly  used  with  success.  The  follow- 
ing day  I  was  again  sent  for  ;  the  bleeding  still  continued. 
After  having  disburdened  the  mouth  of  all  the  lint  pledgets, 
which  I  used  for  making  compression  at  the  place  where  the 
blood  appeared  to  come  from,  I  made  the  patient  take  some 
mouthfuls  of  water  to  clear  his  mouth  of  all  the  clots  of 
blood  with  which  it  Avas  filled  ;  I  perceived,  then,  that  the 
blood  came  no  more  from  the  place  where  I  had  extracted 
the  tooth,  but  from  the  gums  ;  there  was  not  a  single  place 
in  the  whole  mouth  from  which  the  blood  did  not  issue.  I 
called  in  the  physician,  who  ordered  several  bleedings  in 
succession  to  each  other,  besides  astringents,  which  were 
taken  inwardly  ;  and  gargles  of  the  same  nature  were  used  ; 
but  all  these  remedies,  like  all  the  others  he  took  to  give  the 
blood  more  consistence,  were  all  used  to  no  purpose.  It  was 
not  possible  to  stop  this  hemorrhage.  The  patient  died  the 
ninth  or  tenth  day  after  the  extraction  of  the  tooth." 

Mr.  Snell  mentions  a  similar   case  ;  it   also   terminated 
fatally. 


CHAPTER    ELEVENTH. 

THE  USE  OF  ANi:STHETIC  AGENTS  IN  THE  EXTRACTION 

OF  TEETH. 

Of  the  various  agents  tliat  have  been  employed  for  the 
prevention  of  pain  during  surgical  operations,  sulphuric 
ether  and  chloroform  have  proved  more  successful  and  been 
more  generally  used  than  any  other.  The  practicability  of 
doing  this  with  the  former,  was  first  brought  prominently 
before  the  medical  and  dental  profession  in  1846,  by  Dr.W. 
G.  S.  Morton,  dentist,  of  Boston,  Mass.,  and  with  the  lat- 
ter, in  1847,  by  Professor  J.  Y.  Simpson,  of  Edinburgh, 
Scotland.  The  antesthetic  effect  is  obtained  by  inhalation 
of  the  vapor,  and  is  supposed  to  be  nothing  more  than  a 
transient  state  of  intoxication,  which  usually  disappears  al- 
most immediately  after  the  discontinuance  of  the  adminis- 
tration^ though  in  many  cases  it  has  proved  fatal.  For  this 
reason,  we  do  not  think  that  agents  capable  of  producing 
such  powerful  and  dangerous  effects  as  ether  and  chloro- 
form, should  be  used  in  so  simple  an  operation  as  the  ex- 
traction of  a  tooth.  The  first,  however,  is  less  dangerous 
than  the  second.  Its  anaesthetic  effect  is  also  less  certain 
and  less  prompt,  from  seven  to  ten  minutes  being  usually 
required,  whereas  with  the  other,  it  is  obtained  in  from 
thirty  seconds  to  two  minutes,  and  when  ether  is  used, 
from  six  to  ten  or  fifteen  ounces  are  employed  ;  but  with 
chloroform,  it  is  rarely  necessary  to  administer  more  than 
fiom  thirty  to  one  hundred  and  fifty  drops. 

A  number  of  instruments  have  been  gotten  up  for  the  in- 
halation of  the  vapor  of  these  agents,  but  the  simjilest  and, 
we  think,  the  best  metliod  of  administration,  is  from  a  hol- 
low sponge,  or  a  napkin  or  pocket-handkerchief. 


USE   OF   ANESTHETIC  AGENTS.  415 

Although  it  may  not  always  be  possible,  for  any  one,  in 
the  administration  of  either  of  the  foregoing  agents  even 
to  a  person  supposed  to  be  free  from  any  S23ecial  proclivity 
to  disease  from  organic  derangement,  to  pronounce,  a  pri- 
ori, that  no  bad  effect  will  result  from  it ;  all  agree  tha,t  it 
is  unsafe  to  give  it  to  a  patient  laboring  under  disease  of 
the  heart,  brain  or  lungs.  The  practitioner,  therefore, 
whether  medical  or  dental,  should  be  well  assured,  before 
giving  ether  or  chloroform,  and  especially  the  latter,  that 
these  organs  are  not  only  free'  from  disease,  but  also  from 
any  morbid  tendency,  as  ignorance  with  regard  to  this  mat- 
ter might  lead  to  fatal  consequences.  It  should  be  given 
cautiously  under  any  circumstances,  and  the  pulse  should 
never  be  permitted  to  fall,  during  the  inhalation,  below 
sixty,  or  at  most,  fifty-five  beats  a  minute  ;  but  if  from  care- 
lessness or  any  other  cause,  the  patient  should  sink  and  the 
pulsation  cease,  the  agent  should  be  immediately  removed 
from  the  mouth,  and  if  occupying  a  sitting  posture,  he 
should  be  placed  in  a  reclining  position,  air  freely  admit- 
ted, cold  water  dashed  in  the  face,  the  feet  and  hands  rub- 
bed with  hot  salt  or  mustard,  and  if  necessary,  artificial 
respiration  made  and  galvanism  applied. 

It  is  thought  by  those  who  have  had  most  experience  in 
the  use  of  ether  and  chloroform  as  anaesthetic  agents,  that 
their  administration  is  attended  with  less  danger  when  the 
patient  is  in  a  reclining  than  when  in  a  sitting  posture. 
This  being  the  case,  it  would  be  well,  when  either  is  used 
preparatory  to  the  extraction  of  teeth,  to  place  the  patient 
as  nearly  as  possible  in  such  position,  and  when  tlie  dentist 
is  provided  with  a  suitable  operating  chair,  it  can  be  very 
readily  done.* 

Suspension  of  nervous  sensibility,   induced  by  inhaling 

♦  To  admit  of  this,  the  chair  of  the  dentist  should  have  a  movable  back  attached 
on  each  side,  attjje  lower  part  of  the  scat,  by  a  hinge,  and  made  fast  at  any  desired 
angle  by  means  of  a  sort  of  ratchet  quadrant  attached  to  a  rod  passing  through  the 
back,  where  it  comes  in  contact  with  the  arm  pieces,  and  working  through  a  sta- 
ple on  the  outside  of  each  of  the  latter.  Other  chairs  have  also  been  constructed, 
which  admit  of  being  readily  placed  in  almost  any  desired  position. 


416  USE  OF   ANESTHETIC   AGENTS 

the  vapor  of  the  above  mentioned  agents,  or  amylen,  a 
more  recently  discovered  anaesthetic,  is  general — every  part 
of  the  body  being  affected  alike,  but  partial  or  local  anaes- 
thesia may  be  procured  by  other  and  less  dangerous  means. 
Congelation  or  freezing,  as  recommended  by  Dr.  James 
Arnott^  of  London,  has  been  resorted  to  for  several  years, 
both  by  surgeons  and  dentists,  and  practiced  to  a  limited 
extent,  certainly  with  some  success.  This  may  be  effected 
by  applying  a  mixture  of  pounded  ice  and  common  salt  in 
the  proportion  of  two  or  three  ]3arts  of  the  former  to  one  of 
the  latter,  to  the  part  on  which  the  operation  is  to  be  per- 
formed. But  in  the  use  of  this,  care  is  necessary  to  prevent 
reducing  the  temperature  too  low,  as  in  this  case,  loss  of  vi- 
tality would  be  occasioned  by  it.  We  have  heard  of  a  few 
cases  in  which  this  has  occurred,  but  we  believe  it  was 
owing  in  every  instance  to  carelessness  or  want  of  judgment 
on  the  part  of  the  operator,  as  to  the  length  of  time  the 
application  of  the  mixture  should  be  continued. 

Several  instruments  have  been  invented  for  the  applica- 
tion of  the  freezing  mixture  to  teeth  preparatory  to  extrac- 
tion. The  one  best  adapted  for  the  purpose,  which  we  have 
seen,  was  designed  and  gotten  up  by  Dr.  Branch,  of  Chi- 
cago, 111.  It  consists  of  a  hollow  tube  about  an  inch  or  a 
little  more  in  diameter,  with  about  five-eighths  of  an  inch 
on  two  of  the  sides,  the  one  opposite  the  other,  cut  out  at 
one  end,  that  it  may  readily  be  placed  over  a  tooth.  To 
this  is  attached  a  sac,  large  enough  to  hold  a  table-spoonful 
of  the  mixture,  of  finely  prepared  membrane.  The  hollow 
of  the  tube  is  occupied  by  a  steel  wire  spiral  spring.  Be- 
fore using,  a  sufficient  quantity  of  the  freezing  mixture  is 
put  in  the  tube  ;  the  end  of  the  latter  is  placed  over  the 
tooth,  when  the  ice  and  salt  are  forced  up  gently  around  it 
by  pressing  on  the  spring  at  the  other  extremity  of  the  in- 
strument. Two  tubes  are  employed — one  straight  for  teeth 
in  the  anterior  part  of  the  mouth,  the  other  "bent  near  one 
end,  for  the  more  convenient  application  of  the  mixture  to 
a  molar  tooth, 


IN   THE   EXTRACTION   OF  TEETH.  417 

The  sudden  application  of  sucli  intense  cold  to  a  sensitive 
tooth,  or  to  one  which  has  not  lost  its  vitality,  is  often  pro- 
ductive, at  first,  of  severe  pain,  and,  on  this  account,  many 
object  to  the  use  of  it^  preferring  the  momentary  suffering 
consequent  upon  the  operation  of  extraction,  than  that  oc- 
casioned by  the  freezing  mixture.  But  this  effect  is  rarely 
experienced  in  the  use  of  the  agent  on  dead  teeth,  or  the 
roots  of  teeth  which  have  lost  their  vitality,  and  hence,  the 
application  of  it  has  proved  more  satisfactory  to  such  than 
to  living  teeth. 

With  the  view  of  obviating  the  above  objection  to  the  use 
of  cold  as  an  anaesthetic  agent,  Messrs,  Plorne  and  Thorn- 
thwaite,  opticians,  of  London,  at  the  suggestion  of  Mr. 
Blundell,  dentist,  of  that  metropolis,  contrived  and  con- 
structed an  apparatus,  by  which  the  temperature  may  be 
gradually  diminished,  say  from  98°  or  blood  heat,  down  to 
zero,  or  any  required  degree,  thus  preventing  the  pain  con- 
sequent upon  the  sudden  application  of  the  freezing  agent. 
The  apparatus  is  thus  described.  "The  required  amount  of 
water  is  cooled  down  by  means  of  ice  and  salt  to  about  zero, 
in  a  vessel  called  the  refrigerator.  To  this  vessel  is  attached 
another,  called  a  graduator^  containing  warm  water  at 
about  100°,  and  so  constructed  as  to  produce  a  gradually 
diminishing  temperature,  for  the  purpose  of  preventing 
sudden  shock  and  pain  to  the  teeth,  which  a  direct  applica- 
tion of  cold  would  inevitably  cause.  A  tube  conveys  this 
graduating  current  into  a  terminal  portion  constructed  of 
very  fine  membrane,  which  adapts  itself  to  the  form  of  the 
gums,  and  wholly  surrounds  the  tooth  to  be  withdrawn. 
The  fluid  then  passes  away  througli  an  exit  tube.  In  this 
manner  a  constant  current  of  cold,  at  an  invariable  tem- 
perature, is  made  to  pass  over  the  part,  abstracting  there- 
from all  heat,  and  with  it  the  power  of  feeling."  The  gum 
and  alveolar  membrane  being  now  in  a  frozen  condition, 
and,  as  a  consequence,  devoid  of  sensibility,  the  extracting 
instrument  is  applied  and  the  tooth  removed. 

It  is  difficult  to   understand  from  the  foregoing  descrip- 


418  USE   OF   ANESTHETIC   AGENTS 

tion,  the  construction  of  the  apparatus,  and  how  the 
warm  water  first  brought  in  contact  with  the  tooth,  is  grad- 
ually displaced  by  the  current  from  the  refrigerator,  until 
the  temperature  of  the  parts  is  reduced  to  the  freezing  point. 
It  seems  from  what  is  said  of  it,  to  he  admirably  adapted  to 
the  purpose  for  which  it  was  designed. 

In  the  early  part  of  the  present  year  (1858)  Mr.  J.  B. 
Francis,  dentist,  of  Philadelphia,  announced  the  discovery 
of  a  new  and  novel  method  of  j)roducing  local  antesthesia, 
said  to  be  peculiarly  applicable  to  the  extraction  of  teeth  in- 
duced by  passing  an  electro-galvanic  current  through  the 
tooth  the  moment  of  its  removal.  The  discovery  was  submit- 
ted to  the  Franklin  Institute,  Philadelphia,  and  the  commit- 
tee to  whom  it  was  referred  for  examination,  composed  in 
part  of  dentists,,  reported  favorably  in  regard  to  the  claims  of 
the  inventor.*  One  of  the  members  of  this  committee,  states 
that  he  had  extracted  between  four  and  five  hundred  teeth, 
applying  the  electric  current  and  that  in  ninety-five  per 
cent  of  the  cases  without  pain  to  his  patient,  f 

The  method  of  applying  it  is  very  simple.  One  pole,  the 
negative  is  preferable,  of  the  electro-galvanic  machine  is  at- 
tached to  one  of  the  handles  of  the  forceps  by  means  of  a 
flexible  conductor,  while  the  metallic  handle  of  the  other  is 
grasped  by  the  patient,  the  power  of  the  current  being,  pre- 

*  The  following  is  an  extract  from  the  report  referred  to  above.  "The  Com- 
mittee is  satisfied,  from  the  observation  and  experiment  of  its  members,  that  in  a 
large  majority  of  cases  of  extraction  with  this  apparatus,  no  pain  whatever  is  felt  by 
the  patient. 

To  test  the  question  whether  the  effect  might  not  be  simply  mental,  the  circuit 
was  broken  without  the  patient  being  aware  of  it,  when  the  usual  pain  was  expe- 
rienced, although,  in  the  same  patient,  and  on  the  same  occasion,  teeth  had  been 
removed  while  the  current  was  flowing  without  causing  pain. 

In  the  less  successful  cases,  the  teeth  were  broken  and  diseased  below  the  level 
of  the  gum,  and  the  pain,  in  adjusting  the  forceps  previous  to  the  completion  of 
the  circuit  and  the  extraction,  considerable. 

The  sensation  produced  by  the  passage  of  the  current  is  not  painful,  it  being  so 
adjusted  as  to  he  just  jyerceptible  to  the  patient.  The  committee  believes  its  use  to 
be  entirely  without  danger,  and  not  likely  to  be  followed  by  any  unpleasant  after 
effects." 

t  W.  S.  Wilkinson. 


IN  THE   EXTRACTION   OF   TEETH.  419 

vioiis  to  the  operation,  graduated  by  the  piston  of  the  coil, 
while  the  patient  holds  the  forceps  in  the  other  hand.  The 
current  should  only  be  sufficiently  powerful  to  be  distinctly 
felt.  The  circuit  through  the  tooth  is  not  made  until  the 
instant  the  operation  begins.  This  part  is  managed  by  an 
electro-magnet  closing  and  breaking  the  circuit  through  the 
conductors  of  the  positive  and  negative  poles  and  the  body 
of  the  patient.  This  may  be  done  either  by  the  foot  of  the 
operator,  or  by  an  assistant. 

A  small  electro-galvanic  battery,  arranged  for  the  purpose 
having  been  placed  in  the  office  of  the  author,  soon  after 
the  announcement  of  the  discovery,  he  has  had  frequent  op- 
portunities of  applying  this  new  agent  in  the  extraction  of 
teeth,  and  thus  far,  about  nine  out  of  ten  of  those  who  were 
placed  under  its  influence,  while  undergoing  the  operation, 
assured  him  that  they  either  experienced  no  pain  at  all,  or 
only  very  little — not  a  tenth  part  of  what  they  had  experi- 
enced under  the  operation  on  former  occasions.  In  almost 
every  case  in  which  the  tooth  was  grasped,  without  the  instru- 
ment coming  in  contact  with  anything  more  than  the  edge 
of  the  gum  the  operation  appeared  to  be  painless,  or  very 
nearly  so.  But  when  pushed  up  a  considerable  distance  be- 
tween it  and  the  tooth,  the  suffering  was  not  appreciably 
diminished,  the  electric  current  in  such  cases  seeming  to  be 
too  much  diffused.  It  is  stated  by  those  who  have  made  the 
experiment  that  this  diffusion  of  the  electric  current  may  be 
prevented  b}''  insulating  the  outer  portion  of  the  instrument 
with  a  coating  of  gutta-percha  or  by  japaning.  The  author 
has  not  tried  this  expedient. 

How  it  is  that  the  passage  of  an  electric  current  through  a 
tooth  should  prevent  pain  is,  to  the  author,  inexplicable, 
but  that  it  does  in  a  majority  of  cases,  is  attested  by  many 
who  have  been  placed  under  its  influence.  It  may  be  noth- 
ing more  than  a  mere  change  of  sensation,  and  whether  its 
application  will  become  general,  or  its  efficacy  as  an  ansBS- 
tic  agent  be  fully  established,  remains  for  future  experience 
to  settle. 


420  USE   OF   ANiESTHETIC   AGENTS 

As  the  use  of  anaesthetic  agents  of  any  kind  in  the  ex- 
traction of  teeth  is  attended  with  inconvenience,  nearly 
always  procrastinating  the  operation,  the  author  is  of  opin- 
ion that  their  employment,  as  a  general  thing,  should  he  dis- 
pensed  with.  He  never  encourages  their  use,  and  rarely 
finds  it  necessary  to  employ  them.  Indeed  the  extraction  of 
a  tooth  is  so  simple  an  operation,  seldom  requiring  more 
than  from  two  to  five  seconds  for  its  performance,  that  most 
persons  would  rather  submit  to  it  at  once,  than  have  it  pro- 
crastinated by  the  application  of  an  agent  for  the  prevention 
of  the  momentary  pain  which  it  occasions.. 


CHAPTER      TWELFTH. 

ATROPHY  OF  THE  TEETH. 

i  That  peculiar  structural  alteration  of  the  teeth,  desig- 
ciated  atrophy,  is  less  frequent  in  its  occurreuce  than  any 
!)tlier  disease  to  which  these  organs  are  liable,  and  as  the 
progress  of.  the  affection  usually  terminates  with  the  action 
vf  the  causes  concerned  in  its  production,  it  has  scarcely 
^en  deemed  of  sufficient  importance  to  merit  serious  con- 
Kderation,  Hence  neither  its  aetiology  nor  pathology  has 
Deen  very  carefully  investigated.  Indeed,  most  writers  upon 
the  diseases  of  the  teeth  have  overlooked  the  affection  alto- 
gether, while  a  few  have  only  merely  alluded  to  it,  without 
describing  the  characteristics  even  of  its  principal  varieties. 
Whether  we  shall  now  be  able  to  throw  any  additional  light 
upon  the  subject,  or  establish  the  correctness  of  any  opinions 
already  advanced,  or  not,  we  leave  to  others  to  determine. 

The  strict  applicability  of  the  term  atrophy _,  as  the  two 
principal  varieties  of  the  affection  consist  rather  in  a  con- 
genital defect,  most  frequently  of  some  portion  of  the  en- 
amel of  two  or  more  teeth,  than  wasting  from  want  of  nour- 
ishment, of  any  of  the  dental  tissues,  may,  perhaps,  be  con- 
sidered as  somewhat  questionable.  This  would  seem  to  be 
rendered  still  more  so  by  the  fact,  tliat  neither  of  the  varie- 
ties to  which  we  have  referred,  occurs  subsequently  to  the 
formation  of  the  enamel.  But  as  the  congenital  form  of  the 
disease  is  evidently  the  result  of  altered  function  in  a  portion 
of  one  or  more  of  the  formative  organs,  if  not  of  absolute 
degeneration,  from  vicious  nutrition,  we  are  disposed  to  re- 
gard the  term  as  the  most  applicable  of  any  that  can  be  ap- 
plied to  it. 

Mr.  Fox  speaks  of  a  defect,  sometimes  met  with  in  the 


422  ATROPHY   OF   THE  TEETH. 

organization  of  the  enamel,  characterized  bj  yellow  color, 
and  a  great  number  of  indentations  upon  its  surface,  giving 
to  the  teeth  the  appearance  of  "the  exterior  of  a  sponge," 
which  he  termed  "honey-combed."  He  refers  these  defects 
to  a  deviation  from  the  natural  action  of  the  membrane 
which  secretes  the  enamel,  and  dependent  upon  some  "pecu- 
liarity of  constitution,"  during  the  first  months  of  infancy. 
He  thinks  it  is  liable  to  occur  in  several  children  of  the  same 
family^  and  that  teeth  thus  affected  are  less  liable  to  decay 
than  those  which  have  beautiful  and  transparent  enamel.* 

M.  Delabarre,  an  ingenious  physiologist,  and  for  the  most 
part,  a  close  and  very  accurate  observer,  has,  probably, 
approached  nearer  a  correct  explanation  of  the  true  cause  of 
odontatrophia  than  any  other  writer.  But  he  has  evidently 
confounded  one  of  the  varieties  of  the  affection  with  erosion — 
a  disease  characterized  by  essentially  different  phenomena, 
and  produced  by  different  causes.  He  restricts  the  term  to 
the  variety  which  consists  simply  of  discoloration  and  ab- 
sence of  a  portion  of  the  enamel.  In  the  former  cases  he 
believes  it  may  be  congenital  or  accidental,  but  in  the  latter 
he  thinks  it  is  always  congenital.  He  confounds  the  variety 
which  consists  of  perforations  in  the  enamel  with  erosion, f 
But,  so  distinctly  marked  are  the  peculiarities  of  each,  there 
is  no  necessity  for  confounding  the  one  with  the  other. 

The  opinion  of  M.  Delabarre,  with  regard  to  the  cause,  is 
founded  upon  the  supposition,  that  the  doctrine  of  the  forma- 
tion of  the  enamel  as  maintained  by  Hunter,  Jourdain,  Fox 
and  Cuvier,  is  erroneous,  and  that  this  portion  of  a  tooth  is 
formed  from  an  immense  number  of  exhalents  which  cover 
the  crown,  forming  a  "sort  of  imperceptible  velvet." J 
These  he  regards  as  integral  i)arts  of  the  tooth,  and  believ- 
ing the  enamel  fibres  to  be  secreted  by  them,  he  ascribes  the 

*  Natural  History  and  Diseases  of  the  Human  Teeth  ;  American  edition,  pages 
57,  8  and  9. 

t  Traite  de  la  Seconde  Dentition,  pp.  20,  1,  2  and  3. 

I  It  is  scarcely  necessary  to  state  that  the  exhalents  of  Delabarre,  correspond 
exactly  with  the  corpuscles  or  fibres  of  the  enamel  membrane  of  Raschkow. 


ATROPHY  OF  THE  TEETH.  423 

affection  under  consideration  to  their  vicious  development  or 
imperfect  nutrition.  • 

Lefoulon  adopts  the  views  and  almost  the  precise  language 
of  Delaharre,  in  the  description  which  he  gi"^ps  of  the  affec- 
tion. Maury  treats  of  both  it  and  erosion  as  being  one  and 
the  same  disease.  But  in  describing  atrophy  he  notices  the 
distinctive  peculiarities  by  which  each  affection  is  charac- 
terized.* In  describing  the  difference  between  erosion  and 
atrophy,  M.  Delabarre  says,  the  part  atrophied  is  deformed 
and  deprived  of  the  enamel,  ''^that  the  teeth  are  yellow  and 
sensitive,  the  touch  of  the  finger  causing  pain,"  In  erosion, 
if  the  crystals  of  the  enamel  are  not  wholly  destroyed,  ''the 
bottom  of  the  pits  are  of  a  white  color,  and  on  being  touched 
no  disagreeable  sensation  is  experienced  ;  if,  on  the  contrary, 
the  crystals  are  destroyed  to  the  dentine,  the  part  thus  de- 
nuded is  irritable." 

In  an  article  on  erosion^  Maury  gives  a  very  accurate  de- 
scription of  several  varieties  of  atrophy  of  the  teeth.  The 
first,  he  represents  as  consisting  of  irregular  white,  deep  or 
light  yellow  spots,  situated  in  the  enamel  of  the  tooth,  with- 
out affecting  the  smoothness  of  its  surface.  The  second,  as 
characterized  by  little  crowded  holes,  or  irregular  depres- 
sions, resembling  quilting  ;  or  as  consisting  of  transversa 
sinuosities,  single  or  divided  by  prominent  lines,  which^^^ 
sometimes  "yellow,  but  of  the  color  of  the  enamel. "^'^'i^ 
third  variety  affects  the  dentine  as  well  as  the  ena^^^lj  i"^- 
ducing  the  dimensions  of  the  crown  of  the  tooth  "^ometimes 
to  one-third  of  its  natural  size,  and  not  unfrequ  -'^tly  divid- 
ing it  by  a  deep  circular  groove  or  depression. 

Not  one  of  the  phenomena  here  describe**  i®  produced  by 
the  action  of  corrosive  agents,  or  is  the  result  of  chemical 
decomposition  either  of  the  enamel  or  clentine,  but  are  mani- 
festly dependent  upon  other  cau.«^^s.  The  term  erosion, 
therefore,  cannot  be  applied  to  either  variety  of  the  affection 
just  noticed,  with  the  le^st  shov  of  propriety. 

*  Traite  Comclet  de  TAr^  du  Dentiste,  pp.  99  and  100. 


424  ATROPHY   OF   THE   TEETH. 

Odontatrophia  may  very  properly  be  divided  into  three 
varieties*  Each  has  distinctive  peculiarities  which  charac- 
terizes it  from  either  of  the  others.  Two  are  always  con- 
genital, and  tl^  other,  although  most  frequently  congenital, 
sometimes  occurs  subsequently  to  the  eruption  of  the  tooth. 

Although  Maury  has  given  a  better  description  of  the 
three  principal  varieties  of  dental  atrophy  than  any  other 
writer,  he  has  omitted  some  things  which  it  will  be  proper 
to  mention.  But  in  treating  of  tliQse  different  varieties,  we 
shall  change,  somewhat,  the  order  of  the  arrangement 
which  he  has  laid  down. 

First  variety.  The  peculiarities  that  distinguish  this 
variety  of  atrophy  from  either  of  the  others  are,  that  it 
never  impairs  the  uniformity  and  smoothness  of  the  sur- 
face of  the  enamel,  and  is  characterized  by  one  or  more 
white,  or  dark  or  light  brown,  irregularly  shaped  sj)ots. 
upon  the  labial  or  buccal  surface  of  the  tooth.  It  occurs 
oftener  than  the  third  variety,  and  less  frequently  than  the 
second.  It  rarely  appears  on  more  than  one  or  two  teeth  in 
the  same  mouth,  though  several  are  sometimes  marked  by 
it.  It  is  seen  on  the  molars  more  frequently  than  the  bi- 
cuspids, and  much  oftener  on  the  incii.>rs  of  the  upper  jaw 
than  any  of  the  other  teeth.  We  do  not  recollect  to  have 
evfcv  observed  it  on  the  cuspids  of  either  jaw,  nor  on  the 
palatx'^e  or  lingual  surfaces  of  the*incisors. 

The  fc'^amel  is  much  softer  on  the  affected  than  on  the 
unaffected  -Darts  of  the  tooth,  and  may  be  easily  broken  and 
reduced  to  powder  with  a  steel  instrument.  It  seems  to 
be  almost  wh-^Hy  deprived^  in  these  places,  of  its  animal 
constituents  as  veil  as  its  connection  with  the  subjacent 
dentine. 

The  size  of  the  atrophied  spots  are  almost  as  variable  as 
their  shape,  but  the  onljr  harm  resulting  from  them,  is  the 
unpleasant  aspect  they  somotimes  give  to  the  tooth. 

As  we  have  before  remar?<ed,  this  variety  of  atrophy  is 
sometimes  accidental,  occurriig  subsequently  to  the  erup- 
tion of  the  tooth,  but  in  a  large  majority  of  the  cases  it  is 


ATROPHY  OF  THE  TEETH.  425 

congenital.  It  is  rarely  seen  on  a  temporary  tooth.  In  all 
tlie  cases  which  have  come  under  our  observation  it  was  con- 
fined, to  the  best  of  our  recollection,  to  the  teeth  of  second 
dentition. 

Second  variety.  This  may  be  very  properly  denominated 
perforating  or  pitting  atrophy,  as  it  gives  to  the  enamel  an 
indented  or  pitted  appearance,  the  irregular  depressions  or 
holes  extend  transversely  across  and  around  the  tooth.  The 
pits  are  sometimes  more  or  less  distinctly  separated  one 
from  another,  by  prominent  lines  ;  at  other  times  they  are 
confluent,  and  form  an  irregular  horizontal  groove.  Some- 
times they  penetrate  but  a  short  distance  into  the  enamel ; 
at  other  times  they  extend  entirely  through  it  to  the  den- 
tine. Their  surface  though  generally  rough  and  irregular, 
usually  presents  a  glossy  and  polished  appearance — a  pecu- 
liarity which  always  distinguishes  this  variety  of  the  affec- 
tion from  erosion.  The  pits  often  have  a  dark  brownish 
appearance,  though  sometimes  they  are  of  the  color  of  the 
enamel  on  other  parts  of  the  tooth. 

This  variety  of  atrophy  is  never  confined  to  a  single 
tooth.  Two,  four,  six  or  more  corresponding  teeth  are 
always  affected  at  the  same  time,  in  each  jaw,  and  the  cor- 
responding teeth  of  the  same  class  precisely  in  the  sai.. . 
manner,  and  in  the  same  place.  When  more  than  two  are 
marked,  the  distance  of  the  pits  from  the  coronal  extremi- 
ties of  the  organs  varies,  according  to  the  progress  the 
formation  of  the  enamal  had  made  on  each  class  ^t  the  time 
of  the  operation  of  the  causes  concerned  in  the  production 
of  the  afiection.  For  example,  when  the  line  of  pits  in  the 
central  incisors  is  situated  about  two  lines  from  their  cut- 
ting edges,  it  will  scarcely  be  one  line  from  the  cutting 
edges  of  the  laterals,  and  only  the  points  of  the  cuspids 
will  be  marked.  When  the  indentations  are  nearer  the 
edges  of  the  central  incisors,  they  will  be  on  the  edges  of 
the  laterals,  and  the  cuspids  will  have  entirely  escaped. 

Sometimes  the  teeth  are  n.arked  with  two  or  three  rows 
of  pits,  and  when  this  is  the  case,  the  patient  has  either  had 
28 


426 


ATROPHY   OF   THE   TEETH. 


two  or  three  relapses  or  been  attacked  two  or  three  times  in 
quick  succession  with  different  diseases  capable  of  interrupt- 
ing the  progress  of  the  formation  of  the  enamel. 

Although  the  incisors  are  more  frequently  marked  with 
these  indentations  than  any  of  the  other  teeth,  the  cuspids, 
bicuspids,  and  even  the  molars  are  sometimes  affected  with 
them.  When  the  disease  attacks  the  molars,  its  effects  are 
generally  located  on  the  grinding  surface.  The  permanent 
teeth  are  more  liable  to  be  attacked  than  the  temporary. 
We  have  never  known  but  one  instance  in  which  the  latter 
iWere  affected  with  the  disease. 

I  This  variety  of  atrophy  occurs  oftener  than  either  of  the 
others^  and  though  it  sometimes  gives  to  the  teeth  a  very 
disagreeable  and  unsightly  appearance,  it  rarely  increases 
their  liability  to  decay. 

Third  variety.  In  this  variety  of  atrophy  the  whole  or 
only  a  part  of  the  crown  of  a  tooth  may  be  affected — the 
i dentine  being  often  implicated  as  well  as  the  enamel.  The 
jtooth  usually  has  a  pale  yellowish  color,  a  shrivelled  ap- 
pearance, and  is  partially  or  wht.lly  divested  of  the  enamel. 
Sometimes  the  crown  is  not  more  than  one-half  or  one-third 
Hits  natural  size.  Its  sensibility  !•>  usually  greatly  increased, 
»nd  its  susceptibility  to  pain  from  external  impressions  is 
wobderfully  excited  by  acids.  It  is  also  more  liable  than 
the  otiier  teeth  to  be  attacked  by  caries.  The  root  of  the 
looth,  though  rarely,  is  nevertheless  sometimes  affected,  and 
presents  ;\n  irreguiar  knotted  appearance. 

The  dise^v^e  is  often  confined  to  a  single  tooth,  but  it  more 
frequently  shows  itself  on  two  corresponding  teeth  in  the 
same  jaw.  According  to  our  observation,  the  bicuspids  are 
more  liable  to  be  attacked  than  any  of  the  other  teeth.  The 
temporary  teeth  are  rarely  affected  with  it. 

This  variety  of  atrophy  occurs  less  frequently  than  either 
of  the  others,  and  although  it  increases  the  liability  of  the 
affected  organs  to  decay,  they  sometimes  escape  its  attacks 
to  the  twentieth  or  thirtieth  year  of  age. 

In  the  description  which  we  have  given  of  the  three  va- 


CAUSES   OF   ATROPHY   OF   THE  TEETH.  427 

rieties  of  dental  atrophy,  we  may  have  omitted  to  mention 
some  of  the  peculiarities  belonging  to  each,  but  we  believe 
we  have  pointed  out  their  principal  characteristics  with  suf- 
ficient accuracy  to  enable  almost  any  one  to  distinguish  one 
from  another,  and  either  from  erosion. 

CAUSES. 

The  first  variety  is  evidently  produced  by  some  cause  ca- 
pable either  of  preventing  or  destroying  the  bond  of  union 
between  the  enamel  and  subjacent  dentine,  but  what  that 
cause  always  is,  is  a  question  which  it  may  be  difficult  to 
answer.  Subsequently  to  the  eruption  of  the  teeth,  it  may 
be  occasioned  by  mechanical  violence,  but  we  have  never 
known  but  one  case  in  which  it  had  resulted  from  this 
cause,  and  that  was  occasioned  by  a  blow  upon  the  tooth. 

Now,  whether  the  bond  of  union  between  this  portion  of 
the  enamel  and  the  subjacent  dentine  was  immediately  de- 
stroyed by  the  concussion  of  the  blow,  or  whether  it  result- 
ed from  subsequent  inflammation  and  the  death  of  the  in- 
termediary membrane,  is  a  question  which  it  may  not  be 
easy  to  answer.  If  it  were  destroyed  at  once  by  the  blow, 
one  would  be  led  to  suppose  that  the  change  in  the  color  of 
the  enamel  would  have  been  observed  immediately,  but  this 
may  have  resulted  from  some  subsequent  change  or  altera- 
tion in  the  animal  constituents  of  this  part  of  the  enamel, 
which  followed  as  a  consequence  of  the  injury  produced  by 
the  violence  of  the  blow.  These  are  questions,  however, 
which  the  present  state  of  our  knowledge  does  not  enable  us 
to  solve.  But  that  the  white  spot  in  this  case  resulted  as  a 
consequence  of  the  blow,  there  cannot  be  the  least  shadow 
of  doubt. 

But  when  the  affection  is  congenital,  as  it  almost  always 
is,  it  is  dependent  upon  some  other  cause,  possibly  upon  dis- 
ease in  the  pulp,  or  intermediary  membrane,  which  consti- 
tutes the  bond  of  union  between  the  dentine  and  enamel, 
subsequently  to  the  formation  of  the  latter.     But  what  the 


428  CAUSES   OF   ATROPHY    OF   THE   TEETH. 

determining  cause  of  the  disease  of  these  parts  is,  if  the  af- 
fection be  produced  in  this  way,  whether  simple  local  irrita- 
tion, or  general  constitutional  disturbance,  we  are]not  pre- 
pared to  say.  One  would  be  likely  to  suppose,  if  the  atro- 
phied spots  were  occasioned  by  disease  of  the  pulp  or  inter- 
mediary membrane,  the  morbid  action  would  scarcely  con- 
fine itself  to  such  narrow  and  circumscribed  limits.  But, 
whether  the  destruction  of  tlie  intermediary  membrane  of 
the  affected  part  results  as  a  consequence  of  actual  disease, 
or  merely  from  vicious  nutrition^  or  whether  from  some  un- 
known cause,  it  has  failed  to  be  developed  here,  it  is  certain 
that  the  fibres  of  this  portion  of  the  enamel  are  not  united 
to  the  subjacent  dentine;  and^  not  receiving  a  supply  of  nu- 
trient fluid  or  vital  princij)le,  their  animal  frame  work  par- 
tially or  wholly  perishes,  leaving  but  little  more  than  their 
inorganic  constituents. 

The  cause  of  this  variety  of  congenital  atrophy,  it  must 
be  confessed,  is  very  obscure  ;  and  in  the  abscehce  of  posi- 
tive knowledge,  we  can  only  infer  the  cause  from  the  nature 
of  the  afiection.  If  it  does  not  result  from  one  or  other  of 
the  above  mentioned,  it  is  difficult  to  imagine  in  what  way 
it  is  produced. 

The  cause  of  the  second  variety  of  odontatrophia  is,  we 
think,  susceptible  of  a  more  satisfactory  explanation.  The 
formative  organ  of  the  enamel,  as  is  now  generally  admitted, 
consists  of  a  membrane,  composed  almost  wholly  of  short 
hexangular  corpuscles  or  fibres,  which  correspond  in  shape 
and  arrangement  to  the  fibres  of  the  enamel.  This  mem- 
brane is  accurately  moulded  to  the  crown  of  the  tooth,  and 
according  to  Ragchkow,  each  fibre  is  a  secretory  duct,  whose 
peculiar  function  it  is  to  secrete  the  fibre  of  the  enamel  cor- 
responding to  it.  It  should  also  be  borne  in  mind  that  the 
secretion  of  the  earthy  salts  of  the  enamel  commences  at  the 
coronal  extremity  of  the  tooth,  gradually  proceeding  towards 
the  base  of  the  crown.  Now  we  can  readily  conceive  that 
some  constitutional  disease,  by  interrupting  the  secretion  of 
the  earthy  salts  deposited  in  the  enamel  cells  or  secretory 


CAUSES   OF   ATROPHY   OF   THE  TEETH.  429 

ducts  of  the  enamel  membrane,  for  the  formation  of  the 
enamel  fibres,  by  occurring  at  the  time  when  this  process  is 
going  on,  might  prevent  them  from  being  filled,  and  cause 
them  to  wither  or  waste  away,  giving  to  this  portion  of  the 
enamel  the  pitted  appearance  which  characterizes  this  vari- 
ety of  atrophy.  In  other  words,  the  secretion  of  the  inor- 
ganic constituents  of  the  enamel  being  interrupted  for  a 
short  time,  the  horizontal  row  of  cells  in  the  enamel  mem- 
brane, into  which  it  should  be  deposited,  will  not  be  filled, 
consequently,  as  might  readily  be  supposed,  they  will  waste 
away,  leaving  a  circular  row  of  indentations  around  the 
crown  of  the  tooth.  But  as  soon  as  the  constitutional  dis- 
ease has  run  its  course,  the  secretion  of  the  earthy  salts 
will  be  resumed^  and  unless  the  child  experiences  a  relapse, 
or  has  a  second  attack  of  disease,  capable  of  interrupting 
this  secretory  process,  the  other  parts  of  the  enamel  will  be 
well  formed. 

Some  writers  ascribe  the  formation  of  these  pits  in  the  en- 
amel to  the  chemical  action  of  a  corrosive  fluid,  or  to  an 
acidulated  condition  of  the  fluid  contained  in  the  dental  sacs, 
but  those  who  have  done  so,  have  confounded  the  affection 
with  erosion.  We  believe,  however,  it  nearly  always  occurs 
as  a  consecjuence  of  an  eruptive  disease  or  catarrhal  fever 
during  the  ''enameling"  process,  and  there  are  many  facts 
which  go  to  sustain  the  correctness  of  this  opinion.  In 
nearly  all  the  cases  that  have  fallen  under  our  observation, 
it  was  clearly  traceable  to  measles,,  scarlatina,  chicken  pox, 
catarrhal  fever,  or  small  pox.  It  may,  however,  occasion- 
ally be  produced  by  other  constitutional  diseases. 

The  third  variety  of  dental  atrophy,  so  far  as  our  observa- 
tions upon  the  subject  would  seem  to  justify  an  opinion^ 
always  results  from  altered  or  vicious  nutrition,  caused  by 
disease  of  the  pulp  or  enamel  membrane,  or  both,  during 
the  secretion  of  the  dentine  or  enamel,  according  as  one  or 
both  are  affected.  We  are  inclined  to  believe  that  the  dis- 
ease in  the  dental  pulp  or  enamel  membrane  may  be  pro- 
duced either  by  local  or  constitutional  causes,  or  both.    But 


430  CAUSES   OF   ATROPHY   OF   THE  TEETH. 

the  information  wliich  we  have  been  able  to  obtain  concern- 
ing the  state  of  the  general  health,  and  that  of  the  mouth 
at  the  time  of  the  dentinification  of  the  pulp  and  the  secre- 
tion of  the  enamel,  in  the  cases  that  we  have  seen,  has  not 
been  as  satisfactory  as  we  could  have  wished. 

Since  writing  the  foregoing,  the  following  interesting  case 
of  dental  atrophy  has  fallen  under  our  observation  : 

Mrs.  C.  called,  December  16, 1850,  to  consult  us  concern- 
ing her  daughter's  teeth,  which,  from  congenital  defect, 
presented  a  most  unsightly  appearance.  The  girl  was  be- 
tween nine  and  ten  years  of  age.  The  cutting  edges  of  the 
upper  central  incisors  were  badly  pitted  and  very  rough; 
the  corresponding  teeth  in  the  lower  jaw  had  a  transverse 
row  of  pits  passing  around  them,  about  a  sixteenth  of  an 
inch  below  their  cutting  extremities.  Another  row  of  pits, 
so  close  together  as  to  form  a  rough  groove,  encircled  the 
upper  central  incisors,  about  an  eighth  of  an  inch  below  the 
gum,  and  the  laterals  a  little  nearer  their  cutting  edges; 
the  lower  incisors  were  similarly  marked,  but  not  quite  so 
near  the  gum.  The  enamel,  near  the  second  transverse 
row  of  pits,  and  between  it  and  the  incisive  extremities  of 
the  teeth,  was  thin  and  of  a  light  brown  color.  A  little 
above  the  first  row,  on  the  central  incisors,  were  two  or 
three  brown  or  opaque  spots.  The  first  permanent  molars 
were  also  encircled  with  a  row  of  indentations,  about  half 
way  between  their  grinding  surfaces  and  the  gums. 

On  inquiry,  we  learned  from  the  mother  that  the  child 
had  a  light  attack  of  measles  when  between  eleven  and 
twelve  months  old ;  of  scarlet  fever  when  about  fifteen  or 
sixteen  months  of  age,  and  dysentery  at  about  the  twenty- 
first  or  twenty-second  month. 

Now,  here  we  have  the  three  varieties  of  atrophy  on  the 
same  teeth,  and  the  occurrence  of  constitutional  diseases 
about  the  time  when  the  affected  parts  of  the  teeth  must 
have  been  receiving  their  earthy  salts,  would  seem  to  estab- 
lish, very  conclusively,  the  connection  of  the  one  with  the 
other. 


TREATMENT  OF  ATROPHY  OF  THE  TEETH.        431 

TREATMENT. 

The  nature  of  this  affection  is  such  as  not  to  admit  of 
cure.  The  treatment,  therefore,  must  be  preventive  rather 
than  curative.  All  that  can  be  done  is  to  mitigate  the 
severity  of  such  diseases  as  are  supposed  to  produce  it  by 
the  administration  of  proper  remedies.  By  this  means,  the 
effects  may,  perhaps^  be  partially  or  wholly  counteracted. 

It  seldom  happens  that  atrophied  teeth  decay  more  read- 
ily than  others,  so  that  the  only  evil  resulting  from  the 
affection,  is  a  disfiguration  of  the  organs.  When  the  cut- 
ting edges  of  the  incisors  only  are  affected,  the  diseased  part 
may  sometimes  be  removed  with  a  file  without  inflicting  the 
slightest  injury  on  the  teeth. 


CHAPTER     THIRTEENTH. 

NECROSIS   OF   THE   TEETH. 

By  the  term  necrosis,  when  applied  to  a  tooth,  is  meant 
the  death  of  the  entire  organ,  or  of  the  crown  and  inner 
walls  of  the  root,  for  it  often  happens  that  a  degree  of 
vitality  is  kept  up  in  the  outer  portion  of  the  dentine  and 
the  investing  cementum  by  the  peridental  membrane,  long 
after  the  destruction  of  the  pulp  and  lining  membraae. 
When  other  bones  are  affected  with  necrosis,  the  dead  part 
is  thrown  off,  and  the  loss  supplied  by  the  formation  of  new 
bone.  But  the  teeth  are  not  endowed  either  with  exfolia- 
tive or  recuperative  powers. 

The  density  of  a  tooth  is  not  sensibly,  if  at  all,  affected 
by  the  mere  loss  of  vitality,  but  so  great  a  change  takes 
place  in  the  appearance  of  the  organ_,  that  it  might  readily 
be  detected  by  the  most  careless  observer.  After  the  de- 
struction of  the  lining  membrane,  the  tooth  gradually  loses 
its  peculiar  semitranslucent  and  animated  appearance^  as- 
suming a  dingy  or  muddy  brown  color,  and  this  change  is 
more  striking  in  teeth  of  a  soft  than  in  those  of  a  hard 
texture.  The  discoloration,  too,  is  always  more  marked 
when  the  loss  of  vitality  has  resulted  from  a  blow,  than 
when  produced  in  a  more  gradual  manner.  The  discolora- 
tion is  partly  owing  to  the  presence  of  the  disorganized  mat- 
ter in  the  pulp-cavity,  and  partly  to  the  absorption  of  this 
matter  by  the  surrounding  walls  of  dentine. 

After  the  destruction  of  the  lining  membrane,  the  tooth 
may  receive  a  sufficient  amount  of  vitality  from  the  alveclo- 
dental  periosteum  to  prevent  it  from  exerting  a  manifest 
morbid  influence  upon  the  parts  with  which  it  is  immedi- 


TREATMENT   OF  NECROSIS   OP  THE  TEETH.  433 

ately  connected.  Teeth  have  occasionally  been  retained 
under  such  circumstances  with  apparent  impunity  for  fifteen 
or  twenty  years.  But  when  every  part  of  a  tooth  has  lost 
its  vitality,  it  becomes  an  extraneous  body,  and  when  this 
happens,  inflammation  of  the  socket  ensues ;  the  gum  around 
it  becomes  turgid  and  spongy,  bleeds  from  the  slightest  in- 
jury, and  the  organ  gradually  loosens  and  ultimately  drops 
out.  In  the  mean  time,  the  diseased  action  frequently  ex- 
tends to  the  sockets  and  gums  of  the  adjoining  teeth. 

The  front  teeth,  from  being  more  exposed  to  injuries  from 
blows,  are  more  liable  to  necrosis  than  the  molars. 

CAUSES. 

Necrosis  of  the  teeth  may  be  produced  by  a  variety  of 
causes,  such  as  protracted  fevers,  the  long  continued  use  of 
mercurial  medicines,  and  by  caries.  The  immediate  cause, 
however,  when  not  occasioned  by  a  blow  sufficiently  violent 
to  destroy  the  vascular  connection  of  the  tooth  Avith  the  rest 
of  the  system,  is  inflammation  and  suppuration  of  the  lining 
membrane,  or  it  may  result  from  deficiency  of  vital  energy 
and  impaired  nutrition.  The  author  has  met  with  several 
cases  in  which  the  loss  of  vitality  could  not  be  accounted  for 
in  any  other  way.* 

TREATMENT. 

When  a  tooth,  deprived  of  vitality,  is  productive  of  in- 
jury to  the  gums  and  to  the  adjacent  teeth,  it  should  be  im- 
mediately removed ;  for,  however  important  ^or  valuable  it 
may  be,  the  health  and  durability  of  the  others  should  not 
be  jeopardized  by  its  retention. 

When  necrosis  of  a  tooth  is  apprehended,  we  should  en- 
deavor, by  the  application  of  leeches  to  the  gums,  and 
gargling  the  mouth  witli  suitable  astringent  washes,  to  pre- 
vent its  occurrence.     If  this  plan  of  treatment  is  adopted  at 

*  Vide  Spontaneous  Disorganization  of  the  Dental  Pulp. 


434  TREATMENT   OF   NECROSIS   OF   THE  TEETH. 

an  early  period,  it  will  sometimes  prevent  the  loss  of  vital- 
ity ;  but  if  long  neglected,  a  favorable  result  need  not  be 
anticipated. 

When  the  loss  of  vitality  is  confined  to  the  crown  and 
inner  walls  of  the  root,  if  the  former  is  not  seriously  im- 
paired by  caries,  it  may  be  perforated,  and  the  pulp-cavity 
and  root  cleansed  and  filled  in  the  manner  as  directed  in 
another  part  of  this  work.  If  the  necrosed  tooth  is  an  in- 
cisor, the  perforation  should  be  made  from  the  palatine  sur- 
face, provided  the  approximal  surfaces  are  sound.  But  pre- 
viously to  the  introduction  of  a  filling,  the  decomposed  sur- 
faces of  the  walls  of  the  pulp  cavity  should  be  completely 
removed,  and  if  this  does  not  restore  to  the  tooth  its  natural 
color,  the  cavity  should  be  filled  with  raw  cotton,  saturated 
with  a  solution  of  chloride  of  soda,  as  directed  in  another 
chapter.       -  .s-,^     '-'       0/ 


CHAPTER    FOURTEENTH. 

EXOSTOSIS  OF  THE  ROOTS  OF  THE  TEETH. 

This  disease  is  common  to  aU  bones,  but  it  rarely  attacks 
any  other  part  of  a  tooth  than  the  root,  and  usuaUy  com- 
mences at  or  near  the  extremity,  then  extends  upwards,  cover- 
ing a  greater  or  less  portion  of  the  external  surface.  It  some- 
times, however,  commences  upon  the  side  of  the  root  and  forms 
a  large  tubercle ;  at  other  times  the  deposit  of  the  new  bony 
matter  is  spread  over  its  surface,  often  uniformly,  but  more 
frequently  unequally.  The  osseous  matter  thus  deposited, 
is  usually  of  the  color,  consistence  and  structure  of  the  ce- 
mentum,  though  sometimes  it  is  a  little  harder  and  assumes 
a  yellower  tinge.  Indeed,  the  enlargement  is  supposed  to 
be  a  mere  hyper trophied  condition  of  this  substance. 


Fig.  138.  The    deposit    of  osseous 

matter,  is  sometimes  so  con- 
siderable, that  the  roots  of 
two  or  more  teeth  are  firm- 
ly united  by  it.  The  au- 
thor has  several  examples 
of  exodontosis  of  this  des- 
cription. One  of  the  above 
was  presented  to  him  by 
Drs.  Blandin  and  Keynolds, 
of  Columbia,  South  Caroli- 
na. These  with  many  oth- 
er examples  are  in  the  Mu- 
seum of  the  Baltimore  College  of  Dental  Surgery.  There 
is  one  there  of  three  teeth  thus  united.* 

*  This  was  presented  to  the  author  for  the  above  Institute,  by  Dr.  Hawes  of 
New  York. 


436  EXOSTOSIS   OF   THE   ROOTS   OF   THE  TEETH. 

The  most  extraordinary  example  of  dental  exostosis  whicli 
the  author  lias  ever  seen  was  sent  to  him  for  examination  by 
Dr.  V.  M.  Swazey,  dentist,  of  Easton,  Pa.  The  tooth  ap- 
parently is  a  dens  sapientite,  and  the  formation  of  the  exos- 
tosis must  have  commenced  with,  the  dentinification  of  the 
pulp.  It  had  spread  over  every  part  of  the  toothy  the 
crown  as  well  as  tlie  root ;  it  had  ruptured  and  penetrated 
every  part  of  the  enamel  membrane,  but  had  not  wholly  de- 
stroyed the  function  of  this  organ,  as  nodules  of  enamel  are 
seen  in  various  parts  of  the  exostosis.  The  tumor,  includ- 
ing the  tooth,  is  about  as  large  as  a  common  sized  hickory 
nut. 

Exodontosis  often  continues  for  a  long  time  without  pro- 
ducing any  inconvenience  whatever.  It  usually  first  mani- 
fests itself  by  slight  soreness  in  the  affected  tooth,  which  in- 
creases as  the  fang  becomes  enlarged,  until  pain,  either  con- 
stant or  periodical,  and  of  a  character  more  or  less  severe,  is 
experienced. 

The  most  remarkable  case  of  exodontosis  on  record,  is  re~ 
lated  by  Mr.  Fox.  The  subject  was  a  young  lady^  who,  at 
the  time  she  came  to  Mr.  F.,  had  suffered  so  much  and  so 
long,  that  the  palpebrje  of  one  eye  had  been  closed  for  near 
two  months,  and  the  secretion  of  saliva  had,  for  some  time, 
been  so  copious,  that  it  flowed  from  her  mouth,  whenever 
opened.  She  had  tried  every  remedy  science  and  skill  could 
suggest,  without  experiencing  any  permanent  benefit,  and 
was  only  relieved  from  her  suffering  by  the  extraction  ot 
every  one  of  her  teeth. 

In  the  course  of  the  author's  practice,  he  has  removed 
many  teeth  affected  with  exostosis,  but  has  never  met  with 
a  case  similar  to  that  described  by  Mr.  F.  In  one  instance, 
he  was  compelled  to  extract  four  sound  teeth  and  nine  roots ; 
yet  the  pain  was  not,  at  any  time,  severe,  but  it  was  con- 
stant, and  a  source  of  great  annoyance  to  the  patient.  The 
following  is  one  among  the  many  cases  which  have  fallen 
under  his  observation : 

Mr.  S.,  of  Baltimore,  having  sufi^ered  some  time  from  pain 


EXOSTOSIS   OF   THE   ROOTS   OF   THE  TEETH.  43Y 

in  his  first  left  superior  bicuspid,  applied  to  a  dentist  in  1843^ 
for  the  purpose  of  having  the  tooth  removed.  In  the  oper- 
ation, the  root^  about  three-sixteenths  of  an  inch  from  its 
extremity,  was  fractured  and  left  in  the  socket.  In  conse- 
quence of  this,  the  gnawing  pain  with  which  he  had  for  a 
long  time  before  been  troubled,  continued,  and  at  the  expi- 
ration of  twelve  months,  the  gum  over  the  remaining  portion 
of  the  root  became  very  much  swollen,  puffing  out  the  lip  to 
the  sizeof  half  a  hen's  egg.  The  tumor,  after  a  few  days, 
was  opened,  and  a  large  quantity  Of  dark  colored,  purulent,  fe- 
tid matter,  was  discharged,  which,  for  a  short  time,  gave  con- 
siderable relief.  The  tumor,  however,  was  re-formed  and  open- 
ed some  four  or  five  times  in  about  that  number  of  months. 
In  tlie  fall  of  1845,  he  called  upon  us  for  the  purpose  of  ob- 
taining advice.  At  this  time  his  gum  was  swollen,  and  the 
upper  lip  puffed  out  in  the  manner  as  just  described.  On 
opening  the  tumor,  about  three  table-spoonfuls  of  black  mat- 
ter^ resembling  thin  tar,  escaped.  We  then  found,  upon 
examination^  that  the  outer  wall  of  the  antrum,  immediate- 
ly over  the  remaining  portion  of  the  root  of  the  first  bicus- 
pid, was  destroyed,  and  there  was  an  opening  through  it 
large  enough  to  admit  the  fore-finger.  Believing  that  the 
extremity  of  the  root  left  in  the  socket  was  the  cause  of  the 
disease,  we  immediately  proceeded  to  extract  it,  which  we 
succeeded  in  doing  by  the  removal  of  the  outer  wall  of  the 
alveolus.  The  root  was  found,  on  removal,  to  be  enlarged 
by  exostosis,  to  the  size  of  a  very  large  pea.  The  operation 
proved  perfectly  successful,  the  secretion  of  purulent  matter 
soon  ceased,  and  in  a  few  weeks  he  was  completely  relieved 
from  the  troublesome  affection  under  which  he  had  so  long 
labored. 

CAUSES. 

The  primary  cause  of  tliis  disease  does  not  appear  to  be 
well  understood.  Most  writers  concur  in  attributing  the 
proximate  cause  to  irritation  of  the  periosteum  of  the  fang, 


438  EXOSTOSIS   OF   THE   ROOTS   OF   THE  TEETH. 

but  this  is  not;  as  some  suppose,  necessarily  dependent  upon 
any  morbid  condition  of  the  crowns  themselves,  for  it  often 
attacks  teeth  that  are  perfectly  sound.  It  seems  rather  to 
be  attributable  to  some  peculiar  constitutional  diathesis. 

TREATMENT. 

The  disease  having  established  itself  does  not  admit  of 
cure,  and  when  it  has  progressed  so  far  as  to  be  productive 
of  pain  and  inconvenience  to  the  patient,  the  loss  of  the  af- 
fected teeth  becomes  inevitable.  When  the  enlargement  is 
very  considerable  and  confined  to  the  extremity  of  the  root, 
and  has  not  induced  a  corresponding  enlargement  of  the  al- 
veolus around  the  neck  of  the  tooth,  the  remov^  of  the 
affected  organ  is  often  attended  with  difficulty,  and  can  only 
be  effected  by  removing  a  portion  of  the  socket,  or  fractur- 
ing it. 


CHAPTER    FIFTEENTH. 

SPINA  VENTOSA  OF  THE  TEETH. 

Among  the  diseases  whicli  attack  the  teeth,  Mr.  Fox  men- 
tions spina  ventosa,  but  the  author  is  of  the  opinion  that 
the  name  is  not  strictly  applicable  to  the  aflfection  which  he 
treats  of  under  that  designation.  In  medical  language,  this 
term  is  used  to  designate  a  disease  consisting  of  an  ulcerated 
bony  tumor  caused  by  internal  caries,  and  attended  by  a 
prickling  sensation  of  the  flesh. 

Mr.  Fox  describes  the  disease  as  being  seated  in  the  cavity 
of  the  tooth,  and  ^'the  vessels  ramifying  on  its  membrane," 
he  says,  ''acquire  a  diseased  action  by  which  the  membrane 
becomes  thickened,  absorption  of  some  of  the  internal  parts 
of  the  tooth  takes  place,  and  the  opening,  at  the  extremity 
of  the  fang,  also  becomes  enlarged.  This  disease  of  the 
membrane  is  attended  with  the  formation  of  matter,  dis- 
charging itself  at  the  point  of  the  fang,  into  the  alveolar 
cavity,  which,  being  rendered  more  porous  by  the  process  of 
absorption,  affords  an  easy  exit.  During  the  progress  of 
the  disease,  the  gum,  covering  the  alveolar  process_,  becomes 
inflamed,  and  acquires  a  spongy  texture  :  the  matter,  pass- 
ing from  the  socket,  makes  its  escape  into  the  mouth  by 
several  openings  through  the  gum,  which  is  thus  kept  in  a 
constant  state  of  disease." 

Now,  it  will  be  perceived,  that  there  is  little  or  no  analogy 
between  spina  ventosa  and  the  disease  spoken  of  by  Mr.  F. 
under  that  name.  The  latter  is  nothing  more  tlian  the 
effects  of  alveolar  abscess,  arising  from  inflammation  and 
suppuration  of  the  lining  membrane. 


440  TREATMENT   OF   SPINA   VENTOSA. 

When  matter  is  confined  in  the  cavity  of  the  tooth,  the 
canal  in  the  root  may  become  greatly  enlarged.  The  author 
has  met  with  many  cases  where  this  has  happened,  and  he 
has  in  his  possession  several  examples  of  teeth  thus  affected. 

If,  previously  to  the  suppuration  of  the  lining  membrane 
and  pulp,  the  tooth  is  affected  with  exostosis,  the  disease 
would  then  resemble  spina  ventosa. 

CAUSES. 

The  enlargement  of  the  opening  at  the  extremity  of  the 
root,  is  not,  as  Mr.  Fox  believes,  caused  by  the  action  of  the 
absorbents.  Before  this  takes  place,  the  lining  membrane 
has  been  destroyed,  and  the  vital  powers  of  the  root  so  much 
reduced  as  to  preclude  the  possibility,  even  admitting  that  the 
absorbents  are  capable  of  effecting  such  enlargement,  of  its 
being  accomplished  through  their  agency. 

The  enlargement  is  wholly  attributable  to  the  action  of 
the  corrosive  matter  contained  in  the  root.  This  explanation 
appears  the  more  probable  when  we  consider  that  the  matter 
discharged  from  the  socket^  is  ichorous,  offensive,  and  of  a 
corrosive  character. 

Moreover,  spina  vetosa  is  characterized  by  exterior  enlarge- 
ment of  the  bone,  while,  in  the  disease  in  question,  the  size 
of  the  root  is  seldom  increased.  The  external  appearance  of 
the  organ  is  that  of  a  necrosed  tooth. 

TREATMENT. 

A  tooth  affected  with  this  disease  does  not  admit  of  cure. 
The  proper  treatment,  therefore,  consists  in  the  prompt  re- 
moval of  the  organ.  There  are  no  local  nor  general  reme- 
dies which  can  be  applied,  capable  of  affording  relief.  The 
symptoms,  perhaps,  may  sometimes  be  palliated,  but  it  is 
not  advisable  to  tamper  with  a  tooth  thus  affected,  as  it  will 
only  serve  to  protract  and  ultimately  to  augment  the  evil. 


TREATMENT  OF   SPINA   VENTOSA.  441 

It  is  possible  tliat  tlie  occurrence  of  tlie  affection  might, 
in  some  cases,  be  prevented  by  prompt  antiphlogistic  treat- 
ment ;  such,  as  recommended  for  the  prevention  of  necrosis, 
and  for  the  cure  of  tooth-ache  caused  by  inflammation 
of  the  lining  membrane.  But  after  suppuration  has  taken 
place,  and  a  secretion  of  fetid  and  corrosive  matter  been  kept 
up  until  the  canal  of  the  root  has  become  enlarged,  the 
proper  remedial  indication  is  the  removal  of  the  tooth. 


29 


CHAPTER     SIXTEENTH. 

DENUDING  OF  THE  TEETH. 

This  is  one  of  the  most  remarkable  affections  to  which  the 
teeth  are  Hable.  It  consists  in  the  gradual  wasting  of  the 
enamel  on  the  labial  surfaces,  attacking  first  the  central  in- 
cisors, then  the  laterals,  afterwards  the  cuspids  and  bicuspids, 
extending,  sometimes,  to  the  first  and  second  molars.  It 
usually  forms  a  continuous  horizontal  groove,  as  regularly 
and  smoothly  constructed  as  if  it  had  been  made  with  a  file. 
See  Fig.  139.     After  it  has  removed  the  enamel^  it  commits 


Fig.  139. 


Fig.  140. 


its  ravages  upon  the  subjacent  dentine,  sometimes  penetrating 
to  the  pulp-cavity.  It  rarely  changes  the  color  of  the  en- 
amel, but  the  dentine^  after  it  becomes  exposed,  assumes  first 
a  light,  and  afterwards  a  dark-brown  color,  retaining,  how- 
ever, a  smooth  and  polished  surface.  But  this  destructive 
process  does  not  always  commence  at  a  single  point  on  the 
labial  surface  of  the  central  incisors,  in  the  manner  as  just 
described ;  it  sometimes  attacks  several  points  simulta- 
neously. (See  Fig.  140.)  As  it  spreads,  these  unite,  and 
ultimately  a  deep  excavation  is  formed,  with  walls  so  smooth 
and  highly  polished  that  the  tooth  presents  the  appearance 
of  having  been  scooped  out  with  a  broad,  square,  or  round- 
pointed  instrument. 

The  progress  of  the  affection  is  exceedingly  variable.     It 
is  sometimes  so  rapid   that  the  dentine   becomes  exposed 


CAUSES   OF  DENUDING   OF   THE  TEETH,  443 

within  two  or  three  years  from  the  time  of  its  attack  ;  at 
other  times  its  effects  upon  the  enamel  is  scarcely  percept- 
ible for  six  or  eight  years  after  the  discovery  of  its  occur- 
rence. The  author  was  acquainted  with  a  lady  whose  teeth 
were  thus  affected  and  the  denuding  process  did  not  perfo- 
rate the  enamel  for  nearly  twenty  years. 

CAUSES. 

The  cause  of  this  singular  affection  has  never  been  satis- 
factorily explained.  It  was  first  noticed  by  Mr.  Hunter, 
who  calls  it  decay  by  denudation,  and  supposes,  ''from  its 
attacking  certain  teeth  rather  than  others,  and  from  its 
being  confined  to  a  particular  tooth,"  that  it  is  a  disease 
inherent  in  the  tooth  itself,  and  not  dependent  on  circum- 
stances in  after  life. 

Mr,  Bell  thinks  Mr.  H.  has  confounded  the  affection  with 
another,  similar  in  its  appearance,  but  arising  from  a  wholly 
different  cause. 

He  says,  quoting  Mr.  Hunter's- remarks,  ''I  have  seen 
instances  where  it  appeared  as  if  the  outer  surface  of  the 
bony  part,  which  is  in  contact  with  the  inner  surface  of  the 
enamel,  had  first  been  lost,  so  that  the  attraction  of  cohesion 
between  the  two  had  been  destroyed ;  and  as  if  the  enamel 
had  been  separated  for  want  of  support,  for  it  is  terminated 
all  at  once."  '"'In  this  passage,  Mr.  Hunter  describes  very 
accurately  the  result  of  superficial  absorption  of  the  bony 
structure,  a  circumstance  which  I  have  occasionally  seen, 
though  more  rarely  than  the  present  abrasion  of  the  enamel, 
with  which  it  cannot  for  a  moment  be  considered  as  identi- 
cal. In  one  case  the  enamel  is  gradually  and  slowly  removed 
by  a  regular  and  uniform  excavation ;  in  the  other,  the  ab- 
ruptness and  irregularity  of  the  edges,  show  that  it  had 
broken  away  at  once,  from  having  lost  its  subjacent  support. 
The  cause  of  the  former  is  external ;  in  the  latter  it  is  within 
the  enamel." 


444  CAUSES   OF   DENDDINa   OF   THE   TEETH. 

Mr.  Bell,  in  attempting  to  correct  one  error,  has  fallen 
into  another,  equally  great  and  palpable.  He  attributes 
the  breaking  in  of  the  enamel  to  absorption  of  the  subjacent 
dentine,  instead  of  ascribing  it  to  decomposition  by  chemical 
agents,  which  is  the  true  cause. 

In  almost  every  instance,  where  the  author  has  found  the 
edges  of  the  enamel  in  the  condition  as  described  by  Messrs. 
Hunter  and  Bell,  he  has  also  observed  that  the  surface  of 
the  exposed  dentine  was  decayed. 

But  the  breaking  in  of  the  enamel  is  not  the  affection  now 
under  consideration.  That  is  the  result  of  caries  of  the 
subjacent  dentine;  this  a  sort  of  spontaneous  abrasion. 

Mr.  Bell  is  unfortunate,  also,  in  the  suggestions  which  he 
throws  out  in  regard  to  the  cause  of  the  disease.  "What- 
ever may  be  the  cause,"  says  he,  "and  at  present  I  confess 
myself  at  a  loss  to  explain  it,  the  horizontal  direction  in 
which  it  proceeds,  may,  I  think,  be  connected  with  the 
manner  in  which  the  enamel  is  deposited  during  its  forma- 
tion ;  for  it  will  be  recollected,  that  it  first  covers  the  apex 
of  the  tooth,  and  gradually  invests  the  crowns  by  successive 
circular  depositions ;  it  is,  therefore,  not  improbable,  that 
from  some  temporary  cause,  acting  during  its  deposition, 
certain  circular  portions  may  be  more  liable  to  mechanical 
abrasion,  or  other  injury  than  the  rest." 

This  conjecture,  though  it  may  seem  somewhat  plausible, 
is  far  from  satisfactory.  If,  as  he  supposes,  certain  circular 
portions  of  the  enamel  are  less  perfectly  formed  than  others, 
and  consequently  rendered  more  liable  to  the  disease,  it 
would  not  be  wholly  confined  to  the  anterior  surface  of  the 
tooth,  but  would  extend  entirely  around  it,  and  as  soon  as 
these  imperfectly  formed  circular  portions  were  destroyed^ 
its  ravages  would  cease. 

Mr.  Fox  frankly  acknowledges  his  inability  to  assign  any 
cause  for  this  affection ;  but  conjectures  that  it  is  dependent 
on  some  solvent  quality  of  the  saliva.  Were  this  supposi- 
tion correct,  every  part  of  the  tooth  would  be  alike  subject 
to  its  attacks. 


TREATSIENT   OF  DENUDED   TEETH.  445 

Other  writers  suppose  it  is  occasioned  by  the  friction  of 
the  lips.  But  this  hypothesis  is  destitute  of  the  least  sem- 
blance of  plausibility.  The  narrowness  and  depth  of  the 
grooves  are  sometimes  such  as  to  preclude  the  possibility  of 
the  contact  of  the  lips  with  the  interior  surfaces.  Some 
authors,  again,  believe  it  to  be  attributable  to  the  use  of 
tooth  brushes  ;  but  this  is  an  equally  gratuitous  supposi- 
tion. 

The  dentine,  after  it  is  denuded  of  enamel,  is  generally 
quite  sensitive,  and  very  susceptible  of  heat  and  cold. 

The  author  is  of  the  opinion  that  the  loss  of  substance 
which  characterizes  the  affection,  is  produced  by  the  action 
of  acidulated  buccal  mucus.  In  every  other  part  of  the 
mouth  this  fluid  is  mixed  with  saliva,  and  the  acid  it  con- 
tains so  much  diluted  as  to  prevent  it  from  acting  on  other 
portions  of  the  teeth.  That  this  is  the  true  cause,  is  rendered 
almost  certain  by  a  case,  which,  a  few  years  since,  fell  under 
the  observation  of  Dr.  Eleazar  Parmly,  where  the  crowns  of 
human  teeth  which  were  used  for  dental  substitutes,  were 
attacked  in  the  same  manner,  thus  proving,  conclusively, 
that  the  loss  of  substance  was  caused  by  the  action  of  chem- 
ical agents. 

TREATMENT. 

As  a  preventive,  Mr.  Fox  recommends  the  avoidance  of 
whatever  tends  to  produce  it,  but  unfortunately  he  leaves 
his  readers  entirely  in  the  dark  upon  this  subject.  In  ad- 
vanced stages  of  the  affection,  the  author  has  often  succeeded 
in  arresting  its  progress,  by  widening  the  groove  at  the 
bottom,  and  afterwards  filling  it  with  gold.  This,  in  the 
majority  of  cases,  will  prove  successful. 


CHAPTER    SEVENTEENTH. 

SPONTANEOUS  ABRASION  OF  THE  CUTTING  EDGES  OF 
THE  FRONT  TEETH. 

Fig.  141.  The  spontaneous  abrasion 

of  the  cutting  edges  of  the 
front  teeth,  is  an  affection 
of  very  rare  occurrence.  It 
commences  on  the  central 
incisors,  and  from  thence 
proceeds  to  the  laterals,  the  cuspids,  and  sometimes,  though 
very  rarely,  to  the  first  bicuspids.  Teeth  thus  affected, 
have^  when  the  jaws  are  closed,  a  truncated  appearance; 
the  ujDper  and  lower  teeth  do  not  come  together,  and  are 
rather  more  than  ordinarily  susceptible  to  the  action  of 
acids,  and  of  heat  and  cold.  In  other  respects,,  little  or 
no  inconvenience  is  experienced  from  it  until  the  crowns  of 
the  affected  teeth  are  nearly  destroyed. 

Its  progress,  as  in  the  case  of  abrasion  of  the  labial  sur- 
faces, is  exceedingly  variable.  It  sometimes  destroys  half 
or  two-thirds  of  the  crowns  of  the  central  incisors  in  two  or 
three  years;  at  other  times,  seven  or  eight  years  are  re- 
quired for  the  same  effect  to  be  produced  by  it.  In  one  case 
which  came  under  our  own  observation,  the  abrasion  had 
extended  to  the  bicuspids  ;  and  the  central  incisors  of  both 
jaws  were  so  much  wasted,  that  on  closing  the  mouth,  they 
did  not  come  together  by  nearly  three-eighths  of  an  inch  ; 
and  but  two  years  had  elapsed  since  its  commencement.  In 
another  case,  where  it  had  been  going  on  for  seven  years,  it 

FiQ.   141  represents  a  case  of  spontaneous  abrasion,   taken  from  a  drawing 
given  bj  Mr.  Bell. 


ABRASION   OF  THE  EDGES   OF   THE   TEETH.  44*7 

had  not  extended  to  the  cuspids,  and  the  space  between  the 
upper  and  lower  incisors,  did  not  exceed  an  eighth  of  an 
inch.  The  subjects  of  both  were  gentlemen — the  first  aged 
about  twenty-eight,  and  the  other  twenty-one. 

Mr.  Bell  gives  an  interesting  case  of  a  gentleman  whose 
teeth  were  thus  affected  : — "About  fourteen  months  since, 
1831,  this  gentleman,"  says  he,  '^perceived  that  the  edges 
of  the  incisors,  both  above  and  below,  had  become  slightly 
worn  down,  and,  as  it  were,  truncated^  so  that  they  could 
no  longer  be  placed  in  contact  with  each  other.  This  con- 
tinued to  increase  and  extend  to  the  lateral  incisors,  and^ 
afterwards,  successively,  to  the  cuspidati  and  bicuspids. 
There  has  been  no  pain,  and  only  a  trifling  degree  of  un- 
easiness, on  taking  acids,  or  any  very  hot  or  cold  fluids, 
into  the  mouth.  When  I  first  saw  these  teeth,  they  had 
exactly  the  appearance  of  having  been  most  accurately  filed 
down  at  the  edges,  and  then  perfectly  and  beautifully  pol- 
ished :  and  it  has  now  extended  so  far,  that  when  the  mouth 
is  closed,  the  anterior  edges  of  the  incisors  of  the  upper 
and  lower  jaws  are  nearly  a  quarter  of  an  inch  asunder. 
The  cavities  of  those  of  the  upper  jaw  must  have  been  ex- 
posed, but  for  a  very  curious  and  beautiful  provision,  by 
which  they  have  become  gradually  filled  by  a  deposit  of  new 
bony  matter,  perfectly  solid  and  hard,  but  so  transparent 
that  nothing  but  examination  by  actual  contact,  could  con- 
vince an  observer  that  they  were  perfectly  closed.  This  ap- 
pearance is  exceedingly  remarkable,  and  exactly  resembles 
the  transparent  layers  which  are  seen  in  agatose  pebbles, 
surrounded  by  a  more  opaque  mass.  The  surface  is  UDiform, 
even,  and  highly  polished,  and  continuous,  without  the 
least  break,  from  one  tooth  to  another.  It  extends  at  pre- 
sent, to  the  bicuspids,  is  perfectly  equal  on  both  sides,  and 
when  the  molars  are  closed,  the  opening,  by  this  loss  of 
substance  in  front,  is  observed  to  be  widest  in  the  centre, 
diminishing  gradually  and  equally  on  both  sides  to  the  last 
bicuspids." 

Pr,  J.  D.  McCabe  described  to  the  author,  in  1837,  a  case 


448      CAUSES  OF   ABRASION   OF  THE  EDGES   OF  THE  TEETH. 

lie  liad  seen  a  short  time  before,  very  similar  to  the  one 
mentioned  by  Mr.  B.  He  also  gave  him  the  name  and  age 
of  the  individual  and  the  length  of  time  the  abrasion  had 
continued  ;  but  these  he  does  not  recollect  with  sufficient 
accuracy  to  repeat. 

CAUSES. 

With  regard  to  the  cause  of  this  most  extraordinary  af- 
fection, Mr.  Bell,  referring  to  the  case  which  he  describes, 
says,  he  is  'Svholly  at  a  loss  to  offer  even  a  conjecture." 
^'It  cannot  have  been  produced  by  the  friction  of  mastica- 
tion, for  these  teeth  have  never  been  in  contact  since  the 
first  commencement  of  the  affection  ;  nor  does  it  arise  from 
any  apparent  mechanical  cause ;  for  nothing  is  employed  to 
clean  the  teeth,  excepting  a  soft  brush.  Absorption  will 
equally  fail  to  account  for  it ;  for  not  only  would  this  cause 
oj)erate,  as  it  always  doeSj  irregularly,  but  we  find  that,  in- 
stead of  these  teeth  being  the  subjects  of  absorption,  a  new 
deposition  of  bony  matter  is,  in  fact,  going  on,  to  fill  the 
cavities  which  would  otherwise  be  exposed." 

Mr.  Bell  is  correct  in  supposing  that  it  is  not  the  result 
either  of  mechanical  action  or  absorption.  If  then,  neither 
of  these  agencies  are  concerned  in  its  production,  it  must  be 
the  result  of  some  chemical  action,  though  not  of  the  sali- 
vary fluids  of  the  mouth,  for  if  it  was,  every  part  of  the  ex- 
terior surfaces  of  the  teeth  would  be  acted  on  alike.  This, 
as  well  as  the  affection  last  noticed,  the  author  is  disposed 
to  believe,  is  produced  by  the  action  of  acidulated  mucus. 
The  anterior  surfaces  of  the  upper  front  teeth  not  being  so 
frequently  washed  by  the  saliva,  the  mucous  secretions  of 
the  upper  lip,  are  often  permitted  to  remain  on  these  por- 
tions of  the  teeth  for  a  considerable  length  of  time,  and  to 
the  presence  of  this,  Avhen  in  an  acidulated  condition,  we 
believe  the  denuding  process  to  be  attributable,  while  the 
abrasion  of  the  cutting  edges  of  the  incisors  and"cuspidati 
is  caused  by  acid  mucus,  secreted  by  the  mucous  follicles  of 


TREATMENT   OP  ABRASION  OF  THE  TEETH.  449 

the  end  of  the  tongue,  which  is  brought  in  contact  with  the 
cutting  extremities  of  the  front  teeth  almost  constantly^  and 
we  believe  it  is  in  this  way  that  their  loss  of  substance  is 
effected. 

Dr.  Nuhn_,  a  German  physician,  describes  a  gland  which 
he  has  recently  discovered  in  the  interior  of  the  tip  of  the 
tongue.  It  is  rej)resented  as  having  a  number  of  ducts 
opening  through  the  mucous  membrane  over  it.  It  is 
thought  to  be  a  mucous  gland,  and  it  may  be_,  that  this 
gland  in  peculiar  idiosyncrasies,  secretes  the  acidulated 
mucus  concerned  in  the  production  of  the  affection  under 
consideration.  But,  whether  this  hypothesis  be  correct  or 
not,  it  is  evidently  the  result  of  the  action  of  a  chemical 
agent,  and  that  this  is  furnished  by  the  end  of  the  tongue 
is  rendered  more  than  probable  from  the  fact,  that  it  is 
brought  in  contact  with  the  cutting  edges  of  the  teeth,  al- 
most every  time  the  mouth  is  opened. 

TREATMENT. 

This,  like  some  of  the  other  affections  of  the  teeth,  can- 
not be  cured.  If  the  tendency  to  an  acidulated  condition  of 
the  mucous  secretions  of  the  mouth  could  be  overcome  or 
counteracted,  its  progress,  perhaps,  might  be  arrested. 
But,  this  is  a  branch  of  practice  that  comes  rather  within 
the  province  of  the  medical  than  the  dental  practitioner,  so 
that  any  directions  upon  the  subject  here  are  unnecessary. 


CHAPTER    EIGHTEENTH. 
MECHANICAL  ABRASION  OF  THE  TEETH. 

Were  it  true,  as  declared  by  Richerand,  that  tlie  loss  of 
the  enamel  occasioned  by  friction,  is  repaired  by  a  new 
growth,  it  would  never  suffer  permanent  loss  from  me- 
chanical abrasion  ;  but,  the  assertion  is  not  only  untrue, 
but  too  absurd  to  need  refutation. 

The  teeth  rarely  suffer  loss  of  substance  from  friction 
when  the  incisors  of  the  upper  jaw  shut  in  front  of  those  of 
the  lower.  It  is  only  when  the  former  fall  plumb  upon  the 
latter,  that  mechanical  abrasion  of  the  cutting  edges  can 
take  place,  and  when  this  happens,  they  sometimes  suffer 
great  loss  of  substance.  The  crowns  of  these  teeth  are  oc- 
casionally worn  entirely  off,  while  those  of  the  molars  and 
bicuspids  are,  comparatively,  little  affected.  The  reason  of 
this  is,  that  when  the  upper  and  lower  front  teeth  strike 
plumb  upon  each  other,  the  lateral  motions  of  the  jaw  not 
being  restricted,  the  friction  is  greater  at  the  anterior,  than 
at  the  posterior  part  of  the  mouth  ;  consequently,  the  front 
teeth  will  suffer  more  from  abrasion  than  the  molars. 

Sometimes,  the  whole  of  the  teeth  are  worn  off  alike  ;  at 
other  times,  owing  to  the  peculiar  manner  in  which  the 
jaws  come  together^  it  is  confined  to  only  a  few. 

Mr.  Bell  believes  that  certain  kinds  of  diet  tend,  more 
than  others,  to  produce  abrasion  of  teeth.  To  establish  his 
belief,  he  tells  us  that  sailors,  who,  the  greater  portion  of 
their  lives,  live  on  hard  biscuits,  have  only  a  small  part  of 
the  crowns  of  their  teeth  remaining  above  the  edges  of  the 
gums.  But  the  loss  of  substance  is  not  produced  so  much 
by  the  friction  of  masticating  certain  sorts  of  diet  as  by  the 


MECHANICAL  ABRASION   OF  THE  TEETH.  451 

action  of  tlie  lower  teeth  upon  the  upper,  when  those  of  the 
superior  and  inferior  maxillary  sustain  the  relationship  to 
each  other,  just  described. 

When  the  front  teeth  of  the  lower  jaw  strike  against  the 
palatine  surface  of  those  of  the  upper,  the  latter  are  some- 
times worn  more  than  three-fourths  away,  and  in  some  in- 
stances, entirely  up  to  the  gums.  We  have  seen  the  teeth 
of  some  individuals  so  much  abraded^  in  this  way,  that  but 
little  of  their  crowns  remained,  except  the  enamel  of  their 
anterior  surfaces. 

The  wearing  away  of  the  crowns  of  the  teeth  would  ex- 
pose the  lining  membrane,  were  it  not  that  nature,  in  an- 
ticipation of  the  event,  sets  up  an  action  by  which  the  pulps 
are  transformed  into  a  substance  called  osteo-dentine,  which 
is  identical  in  structure  with  cementum.  By  this  beautiful 
operation  of  the  economy,  the  painful  consequences  that 
would  otherwise  result,  are  wholly  prevented. 

The  loss  of  the  crowns  of  the  upper  incisors  and  cuspids 
may  sometimes  be  advantageously  replaced  with  substitutes 
attached  to  the  remaining  roots  of  the  natural  organs.  See 
Manner  of  Preparing  a  Natural  Root  and  Inserting  a  Pivot 
Tooth. 


CHAPTER    NINETEENTH. 

FRACTURES  AND  OTHER  INJURIES  OF  THE  TEETH  FROM 
MECHANICAL  VIOLENCE. 

The  injuries  to  wliicli  teeth  are  subject  from  mechanical 
violence^  are  so  variable  in  their  character  and  results,  as  to 
render  a  detailed  description  impossible.  The  same  amount 
of  violence  inflicted  upon  a  tooth  does  not  always  produce 
the  same  effect.  The  nature  and  extent  of  the  injury  will 
depend  as  much  upon  the  physical  condition  of  the  teeth, 
the  state  of  the  constitutional  health  and  the  susceptibility 
of  the  body  to  morbid  impressions,  as  upon  the  violence  of 
the  blow.  Thus,  a  blow  sufficiently  severe  to  loosen  a 
tooth,  might  not,  in  one  case,  be  productive  of  any  perma- 
nent bad  consequences,  while  in  another,  it  might  cause  the 
death  of  the  organ  and  inflammation  of  the  adjacent  parts, 
as  well  as  necrosis  of  the  alveolus. 

A  tooth  of  compact  texture,  and  in  a  healthy  mouth, 
may  be  deprived  of  a  portion  of  its  substance  without  any 
serious  injury  ;  but  a  similar  loss  of  substance  of  a  tooth, 
not  so  dense  in  its  structure,  would  be  likely  to  produce  in- 
flammation and  suppuration  of  the  lining  membrane,  and 
possibly  of  the  alveolo-dental  periosteum.  Hence,  in  order 
to  form  a  correct  opinion  of  the  result  of  injuries  of  this 
sort,  we  must  take  into  consideration,  not  only  the  charac- 
ter of  the  tooth  upon  which  the  blow  has  been  inflicted,  but 
also  the  state  of  the  health  of  the  mouth  and  of  the  indi- 
vidual. 

If  the  tooth  is  not  loosened  in  its  socket,  any  injury  re- 
sulting from  the  loss  of  a  small  portion  of  the  enamel,  or 
even  of  the  dentine,  may  be  prevented  by  smoothing  the 


INJURIES  FROM  MECHANICAL  VIOLENCE.  453 

fractured  surface  with  a  file,  that  the  juices  of  the  mouth 
and  ]3articles  of  extraneous  matter,  may  not  be  retained  in 
contact  with  it.  But  if  the  tooth  is  loosened,  and  inflam- 
mation of  the  investing  membrane  supervene,  leeches  should 
be  applied  to  the  gums,  and  the  mouth  Avashed  several  times 
a  day,  with  some  astringent  lotion,  until  the  inflammation 
subsides. 

When  a  tooth  has  been  displaced  from  its  socket  by  a 
blow,  and  its  vascular  connection  with  the  general  system 
destroyed,  necrosis  must,  as  a  necessary  consequence,  be  the 
result.  An  imperfect  union  between  the  tooth  and  alveolus 
may  sometimes  be  established  by  the  efiusion  of  coagulable 
lymph,  and  the  formation  of  an  imperfectly  organized  mem- 
brane ;  but  the  tooth  will  ever  after,  from  the  slightest  cold, 
or  derangement  of  the  digestive  organs,  be  liable  to  become 
sore  to  the  touch,  and  in  most  cases  will  ultimately  assume 
a  muddy-brown,  unhealthy  appearance. 

The  author  has,  on  several  occasions,  replaced  teeth  that 
had  been  knocked  from  their  sockets  ;  but  in  only  two  in- 
stances was  the  oiDcration  attended  with  anything  like  suc- 
cess. The  subject  in  one  case  was  a  healthy  boy,  of  about 
thirteen  years  of  age,  who,  while  j)laying  bandy,  received  a 
blow  from  the  club  of  one  of  his  playmates,  wliich  knocked 
the  left  central  incisor  of  the  upper  jaw  entirely  out  of  its 
socket.  He  saw  the  boy  about  fifteen  minutes  after  the  acci- 
dent. The  alveolus  was  filled  with  coagulated  blood.  This 
he  sponged  out,  and,  after  having  bathed  the  tooth  in  tepid 
water,  carefully  and  accurately  replaced  it  in  its  socket,  and 
secured  it  there  by  silk  ligatures  attached  to  the  adjacent 
teeth.  On  the  following  day,  the  gums  around  the  tooth 
were  considerably  inflamed  ;  to  reduce  which,  he  directed 
the  application  of  three  leeches,  and  the  frequent  use  of  di- 
luted tinct.  myrrh,  as  a  wash  for  the  mouth.  At  the  expi- 
ration of  four  weeks,  the  tooth  became  firmly  fixed  in  its  sock- 
et, but  from  the  efl'usion  of  coagulable  lymph,  the  alveolar 
membrane  was  thickened,  and  the  tooth,  in  consequence, 


454  INJURIES  FROM   MECHANICAL  ^TiOLENCE, 

somewhat  protruded.  A  slight  soreness,  on  taking  cold, 
has  ever  since  been  experienced. 

Dr.  Noyes,  dentist,  of  Baltimore,  mentioned  to  the  au- 
thor, a  case  of  a  somewhat  similar  character.  The  subject 
was  a  boy  of  about  ten  years  of  age.  One  of  his  front  teeth 
was  forced  from  its  socket  by  a  fall.  It  was  replaced  shortly 
after,  and  in  a  few  weeks,  became  firm  in  its  alveolus.  Mr. 
Bell  also  mentions  a  case,  attended  with  a  like  result. 

The  alveolar  processes  and  jaw-bones  are  sometimes  seri- 
ously injured  by  mechanical  violence.  In  1834,  the  author 
was  requested  by  the  late  Dr.  Baker,  of  Baltimore,  to  visit, 
with  him,  a  lady  who^  by  the  upsetting  of  a  stage  between 
Washington  and  Baltimore,  had  her  face  severely  bruised 
and  lacerated.  All  that  portion  of  the  lower  jaw,  which 
contained  the  six  anterior  teeth,  was  splintered  off,  and  only 
retained  in  the  mouth  by  the  gums  and  integuments,  with 
which  it  was  connected.  The  wounds  of  her  face,  having 
been  properly  dressed,  the  detached  portion  of  the  jaw  was 
carefully  adjusted  and  secured  by  a  ligature  passed  around 
the  front  teeth  and  first  molars,,  and  by  a  bandage  on  the 
outside,  around  the  chin  and  back  part  of  the  head.  Her 
mouth  was  washed,  five  or  six  times  a  day,  with  diluted 
tinct.  of  myrrh.  The  third  day  after  the  accident,  by  the 
direction  of  Dr.  B.,  she  lost  twelve  ounces  of  blood  ;  and, 
in  five  or  six  weeks,  with  no  other  treatment  than  the  dress- 
ing of  the  wounds,  she  perfectly  recovered. 

It  often  happens,  that  the  crown  of  a  tooth  is  broken  off 
at  the  neck.  We  have  known  the  crowns  of  four,  and  in 
one  case  of  thirteen  teeth  to  be  fractured  from  a  single  blow. 
The  subject  of  the  last  case  was  a  fireman  of  Baltimore, 
who,  in  1835,  received  an  accidental  blow  in  his  mouth  from 
the  head  of  an  axe,  which  broke  off"  the  crowns  of  all  the  up- 
per and  lower  incisors,  two  cuspids  and  three  of  the  bicus- 
pids of  the  inferior  maxillary.  The  subject  of  the  other 
case  was  a  boy  about  twelve  years  of  age,  who,  from  a  sim- 
ilar accident,  occasioned  by  running  up  suddenly  behind  a 
man  who  w^s  chopping  wood,  had  the  crowns  of  his  upper 


INJURIES  FROM  MECHANICAL  VIOLENCE.  455 

incisors  broken  off.  In  both,  of  these  cases^  the  inflamma- 
tion which  supervened  was  so  great  as  to  render  the  remov- 
al of  the  roots  necessary.  The  crowns,  fangs,  and  alveolar 
processes^  are  sometimes  ground  to  pieces,  or  the  teeth 
driven  into  the  very  substance  of  the  jaw,  Mr.  Bell  says,  he 
once  found  a  central  incisor  so  completely  forced  into  the 
bone,  that  he  thought  it  to  be  the  remains  of  a  fang,  but,  on 
removing  it,  found  it  to  be  an  entire  tooth. 

When  the  crown  of  a  tooth  has  been  broken  off  by  a  blow^ 
the  root  should,  as  a  general  rule;,  be  immediately  extracted 
because  the  injury  it  has  received  will  seldom  permit  it  to 
remain  with  impunity.  We  have  sometimes  engrafted  arti- 
ficial crowns  on  such  roots,  but  the  practice  is  usually  a  bad 
one.  If  the  tooth  is  to  be  replaced  with  an  artificial  substi- 
tute, the  root  should  be  first  extracted. 

But,  whether  the  loss  of  the  crown  be  replaced  or  not,  the 
root  can  seldom  remain  without  injury,  for  after  the  inflam- 
mation, induced  by  the  concussion  of  the  blow,  has  sufficient- 
ly subsided,  or  terminated  in  suppuration  of  the  lining 
membrane,  which  it  usually  does,  it  acts  as  a  morbid  irri- 
tant to  the  socket  and  adjacent  parts,  and  for  this  reason 
should  be  removed. 


CHAPTER      TWENTIETH. 
DISEASES  OF  THE  DENTAL  PULP  AND  PERIOSTEUM. 

The  pulp  of  a  tooth,  from  the  high  degree  of  vitality  with 
which  it  is  endowed,  is  one  of  the  most  sensitive  structures 
of  the  body,  and  like  other  parts  is  liable  to  become  the  seat 
of  various  morbid  phenomena.  Its  susceptibility,  too,  to 
morbid  impressions,  is  influenced  by  a  variety  of  circum- 
stances, such  as  temperament,  habit  of  body,  the  state  of  the 
constitutional  health,  the  condition  of  the  hard  structures 
of  the  tooth,  etc.  A  cause,  which  under  some  circumstances 
would  not  be  productive  of  the  slightest  disturbance,  might, 
under  others,  give  rise  to  active  inflammation,  together 
with  all  its  painful  and  disagreeable  concomitants.  In- 
creased irritability  may  exist  independently  of  any  organic 
change,  either  in  the  pulp,  dentine  or  enamel.  Examples 
of  this  are  often  met  with  in  females  during  gestation  ;  but 
it  arises  more  frequently  as  a  consequence  of  caries  of  the 
tooth  than  from  any  other  cause.  Even  before  the  disease 
has  penetrated  to  the  central  chamber  of  the  organ,  the 
pulp,  either  from  functional  disturbance  arising  from  de- 
composition of  the  dentine,  impaired  relationship  between 
the  two,  or  from  being  more  exposed  to  the  action  of  exter- 
nal deleterious  agents,  often  assumes  a  most  wonderful  and 
marked  increase  of  irritability .  Impaired  digestion,  as  well 
as  a  disordered  state  of  other  functions  of  the  body,  fre- 
quently produces  the  same  effect. 

The  susceptibility  of  the  pulp  to  impressions  of  heat  and 
cold,  and  of  acids,  is  always  increased  by  heightened  irrita- 
bility.    When  this  exists  to  any  considerable  degree,  the 


DISEASES   OF   THE  DENTAL   PULP   AND   PERIOSTEUM.         457 

iiere  contact  of  tliese  agents  with  the  tooth,  is  often  produc- 
'ive  of  severe  pain,  which,  on  their  removal,  usually,  very- 
soon  subsides.  The  pulp,  however,  may  remain  in  this 
condition  for  months,  and  even  years,  without  becoming 
the  seat  of  inflammatory  action. 

Preternatural  sensibility  of  the  dentine,*  whether  in  a 
sound  or  partially  decomposed  state,  augments  very  ajjpre- 
ciably,  the  irritability  of  the  pulp.  Impressions  of  heat  and 
cold  conveyed  through  the  conducting  medium  of  a  metallic 
filling,  or  of  a  thin  covering  of  dentine,  as  sometimes  hap- 
pens when  a  considerable  ix)rtion  of  the  tooth  has  been  worn 
away,  is  also  a  very  frequent  cause  of  heightened  irritability 
of  the  pulp.  With  its  susceptibility  thus  increased,  the  im- 
pressions produced  by  these  agents  are  often  a  source  of  irri- 
tation, and  even  of  inflammation  and  suppuration,  causing 
the  death  of  the  entire  crown  and  inner  walls  of  the  root  of 
the  tooth.  At  other  times,  the  irritation  is  only  followed 
by  slight  increase  of  vascular  action  and  an  effusion  of  jilas- 
tic  lymph  over  the  affected  i^art  of  the  pulp,  which  is  grad- 
ually converted,  first  into  callus,  and  then  into  osteo-dentine; 
thus  an  additional  barrier  is  interposed  between  it  and  the 
irritating  agents, 

IRRITATION. 

The  pulp  of  a  tooth  may  become  the  seat  of  severe  pain 
when  there  is  no  inflammation  in  it.  The  slightest  increase 
of  vascular  action,  when  this  organ  is  in  a  preternaturally 
irritable  condition,  is  productive  of  more  or  less  irritation. 
The  pressure  of  the  slightly  distended  vessels  upon  the  ner- 
vous filaments  distributed  upon  it,  at  such  times,  is  sufii- 
cicnt  to  cause  great  pain. 

Impressions  of  heat  and  cold  are  conveyed  more  readily  to 
the  pulp  when  the  dentine  is  in  a  morbidly  sensitive  condi- 

*  The  sensibility  of  dentine  is  sometimes  so  much  increased  that  the  mere  contact 
of  a  hard  substance  with  a  part  which  has  become  exposed  by  the  destruction  of  a 
portion  of  the  enamel,  is  often  productive  of  severe  pain. 

30 


458         DISEASES   OF  THE  DENTAL   PULP  AND   PERIOSTEUM. 

tion,  and  when  tliis  is  the  case,  they  produce  a  more  power- 
ful effect. 

The  remedial  indications  of  pain  in  a  tooth  arising  simply 
from  irritation  of  the  pulp,  consists  in  the  removal  of  the 
primary  and  exciting  causes.  When  produced  by  impres- 
sions of  heat  and  cold  conveyed  to  it  through  the  conduct- 
ing medium  of  a  metallic  filling,  and  intervening  supersen- 
sitive dentine,  the  filling,  if  the  severity  and  continuance  of 
the  pain  is  such  as  to  warrant  the  belief  that  it  will  give 
rise  to  inflammation,  should  be  removed  and  some  non-con- 
ducting substance  placed  in  the  bottom  of  the  cavity  pre- 
viously to  replacing  it.  If  this  is  done  before  inflamma- 
tion actually  takes  place,  it  will  prevent  subsequent  irrita- 
tion from  these  causes.  It  is  worthy  of  remark,  however, 
that  the  pain  thus  produced,  is  in  proportion  to  the  sensi- 
bility of  the  subjacent  dentine.  If  this  is  destroyed  pre- 
viously to  filling  the  tooth,  their  action  upon  the  pulp  will 
be  as  effectually  prevented  as  by  the  interposition  of  a  non- 
conducting substance.  But  in  tlie  application  of  agents  for 
this  purpose,  there  is  danger  of  destroying  the  vitality  of 
the  pulj).  The  employment  of  them,  however,  is  resorted 
to  more  frequently  to  prevent  pain  during  the  removal  of 
caries  than  subsequent  irritation  from  impressions  of  heat 
and  cold. 

Arsenious  acid,  cobalt,  chloride  of  zinc,  and  the  actual 
cautery,  have  all  been  employed  in  the  treatment  of  sensi- 
tive dentine. 

The  use  of  arsenious  acid  in  dental  practice,,  has  hitherto 
been  chiefly  confined  to  the  destruction  of  the  vitality  of  the 
pulps  of  teeth,  but  it  will  also  destroy  the  sensibility  of  the 
dentine,  and  thus  enable  the  operator  to  remove  the  semi- 
decomposed  parts  of  a  sensitive  carious  tooth,  preparatory  to 
filling,  without  pain.  In  employing  it  for  this  purpose, 
however,  great  care  is  necessary  to  prevent  the  destruction 
of  the  vitality  of  the  pulp,  and  the  injection  of  the  vessels  of 
the  dentine  with  red  blood.  This  is  very  liable  to  hapi)en 
when  applied  to  a  tooth  of  a  very  soft  texture,  especially 


DISEASES   OF  THE   DENTAL   PULP  AND   PERIOSTEUM.         459 

if  in  the  mouth  of  a  young  person,  and  when  the  caries  ex- 
tends nearly  to  the  pulp-cavity.  The  action  of  the  arsenic, 
through  the  intervening  hard  structures,  on  the  pulp, 
would  seem_,  in  the  first  instance,  to  cause,  in  some  way  or 
other,  the  decomposition  of  the  red  globules  of  the  bloody 
whereby  a  pinkish-purple  tinge  is  imparted  to  the  serous 
portion  of  this  fluid,  which  is  conveyed  to  every  part  of  the 
dentine.  It  seems,  too,  to  exert  some  peculiar  action  upon 
the  microscopic  vessels  of  this  tissue,  for  the  fluid  which 
they  circulate  is  now  evidently  everywhere  effused  from 
their  coats  and  brought  in  direct  contact  with  the  earthy 
salts,  coloring  them  so  deeply  as  to  impart  to  the  crown  of 
the  tooth  a  pinkish  or  purple  hue,  distinctly  seen  through 
the  translucent  enamel  covering.  Three  or  four  cases  in 
which  this  has  happened  have  occurred  in  the  practice  of 
the  author. 

But  the  ai^plication  of  arsenic  to  a  tooth  is  not  ncecesarily 
followed  by  this  effect.  It  is  only  in  young  persons,  and  in 
teeth  of  a  very  soft  texture,  that  it  is  liable  to  be  produced, 
unless  it  is  permitted  to  remain  in  the  tooth  a  long  time. 
When  it  is  used  merely  for  the  purpose  of  destroying  the 
vitality  of  the  surface  of  the  dentine  at  the  bottom  of  the 
cavity,  preparatory  to  the  introduction  of  a  filling,  and  to 
prevent  irritation  of  the  pulp  from  impressions  of  heat  and 
cold,  it  should  never  be  permitted  to  remain  more  than  two 
hours.  At  the  expiration  of  this  time  it  should  be  removed 
and  after  thoroughly  washing  and  drying  the  cavity,  the 
filling  may  be  introduced,  without  danger  of  subsequent 
irritation  of  the  pulp  or  discoloration  of  the  tooth.  The 
thirtieth,  fortieth,  or  even  fiftieth  part  of  a  grain,  with  an 
equal  quantity  of  sulphate  of  morphia,  is  sufficient  to  apply 
to  a  tooth.  It  should  be  placed  directly  upon  the  bottom  of 
the  cavity,  on  a  dossil  of  raw  cotton  or  lint,  moistened  with 
creosote.  After  the  arsenic  has  been  applied,  the  cavity 
should  be  carefully  filled  with  wax,  mastic,  or  Hill's  stop- 
ping, to  prevent  the  possibility  of  its  escaping  into  the 
mouth  and  to  exclude  the  buccal  fluids.     When  the  cavity 


1 


460         DISEASES   OF   THE   DENTAL   PULP  AND   PERIOSTEUM. 

is  in  the  approximal  surface  of  the  tooth,  additional  security 
may  be  obtained  by  passing  a  ligature  of  floss  silk  three  or 
four  times  around  it  and  tying.  A  small  ring  cut  from  the 
end  of  a  tube  of  caoutchouc  placed  on  the  tooth  is  even  bet- 
ter than  a  ligature  of  silk. 

Professor  Arthur  recommends  the  use  of  cobalt  for  de- 
stroying morbid  sensibility  of  dentine.  He  has  used  it  for 
several  years,  and  believes  it  to  be  as  certain  in  its  effects  as 
arsenious  acid  and  less  liable  to  injure  the  pulp  of  the  tooth. 
It  is  the  arsenic,  however,  with  which  the  cobalt  is  com- 
bined that  produces  the  effect,  but  Professor  A.  is  of  the 
opinion  its  union  with  this  renders  it  less  liable  to  be  taken 
into  the  dentine  by  absorption,  and  as  a  consequence,  less 
liable  to  produce  a  deleterious  action  upon  the  pulp.  It  is 
used  in  the  form  of  a  brownish-black  oxyd,  reduced  to  a  fine 
powder,  and  applied  to  the  tooth  in  the  same  manner  as  ar- 
senious acid. 

But  for  the  destruction  merely  of  morbid  sensibility  of  the 
solid  structures  of  a  tooth,  chloride  of  zinc,  according  to  the 
author's  experience,  although  somewhat  less  certain  in  its 
effects^  is  superior  to  any  preparation  dependent  for  its  ac- 
tive properties  upon  the  presence  of  arsenic.  With  this 
agent  it  rarely  happens  that  more  than  five  minutes  are  re- 
quired to  obtain  the  desired  effect.  Although  a  powerful 
escharotic,  it  does  not,  as  all  arsenical  preparations  are 
liable  to  do,  produce  any  deleterious  effect  on  the  pulp  of 
the  tooth.  When  first  applied,  it  excites  a  sensation  of 
heat,  followed  by  burning  pain^  but  these  soon  subside,  and 
on  removing  it  from  the  tooth,  the  parts  of  the  cavity  with 
which  it  was  in  contact,  will,  in  a  large  majority  of  the 
cases,  be  found  totally  insensible  to  the  touch  of  an  instru- 
ment. Dr.  r.  N.  Seaburg,  in  the  Dental  Times,  relates  a 
case  in  which  he  applied  it  directly  to  the  exposed  pulp  of 
an  aching  tooth.  The  pain^  which  at  first  was  increased, 
soon  subsided,  and  after  removing  the  chloride,  the  tooth 
was  filled  in  the  usual  way,  without  inconvenience  to  the 
patient. 


DISEASES   OF   THE   DENTAL   PULP  AND   PERIOSTEUM,         461 

Tlie  chloride  may  be  applied  directly  to  tlie  cavity  of  a 
sensitive  tootli,  without  being  combined  with  any  other  sub- 
stance, on  a  little  raw  cotton  or  lint,  or  it  may  be  made  into 
a  paste  by  mixing  it  with  an  equal  quantity  of  flour,  the 
moisture  which  it  absorbs  from  the  atmosphere  being  suffi- 
cient for  the  formation  of  the  paste,  or  it  may  be  mixed  with 
a  little  pure  anhydrous  sulphate  of  lime,  in  an  impalpable 
powder^  and  then  applied  to  the  tooth.  But  before  this  is 
done,  as  much  of  the  decomposed  dentine  as  possible  should 
be  removed,  and  the  aj^plication  should  be  held  firmly  in 
contact  with  the  part  of  the  cavity  ui)on  which  it  is  desired 
that  it  should  act.  This  may  be  done  by  filling  the  cavity 
after  it  has  been  put  in,  with  softened  wax  or  raw  cotton. 
The  chloride  may  remain  in  the  tooth  from  five  to  ten  min- 
utes, or  until  the  burning  sensation  produced  by  it  ceases. 
A  single  application  will  generally  suffice  to  destroy  the 
sensibility  of  the  walls  of  the  cavity  to  a  sufficient  depth 
to  enable  the  operator  to  remove  any  remaining  portions  of 
decayed  dentine  without  pain,  and  to  obtund  the  vitality  of 
the  floor  of  the  bottom  sufficiently  to  prevent  the  transmis- 
sion of  impressions  of  heat  and  cold  to  the  pulp.  A  second, 
and  even  a  third  application,  however,  will  sometimes  be 
required. 

The  actual  cautery  was  at  one  time  much  used  and  highly 
recommended  by  French  dentists  in  the  treatment  of  sensi- 
tive decayed  teeth,  but  the  use  of  it  was  long  since  laid  aside 
by  American  and  English  dentists,  as  the  application  gave 
rise^  very  often,  to  inflammation  of  the  pulp. 

Less  potent  agents,  sucli  as  pulverized  galls,  tannic  acid, 
&c.,  have  been  employed  for  the  purpose  of  destroying 
morbid  sensibility  in  teeth  preparatory  to  filling,  and  some- 
times with  good  results. 

Having  noticed  the  agents  usually  employed  for  destroy- 
ing morbid  sensibility  in  dentine  as  a  means  of  preventing 
irritation,  from  impressions  of  heat  and  cold,  of  the  dental 
pulp,  we  will  proceed  to  notice  a  few  of  the  non-conductors 
of  caloric  that  have  been  used  for  the  accomplishment  of  the 


1 


462  DISEASES  OF  THE  DENTAL  PULP  AND   PERIOSTEUM. 

same  object.  Among  tlie  substances  wbicli  have  been  em- 
ployed for  this  purpose,  are,  asbestos,  gutta  percha,  Hill's 
stopinng,  which  is  a  compound  of  gutta  percha,  carbonate  of 
lime  and  some  other  earthy  salts,  cork  and  oiled  silk. 

Asbestos,  as  a  non-conductor  of  caloric,  certainly  possesses 
every  desirable  property,  and  is  as  indestructible  in  a  tooth 
as  gold.  When  used  for  this  purpose,  the  purest  variety 
should  be  selected.  A  small  pellet,  made  from  the  filaments 
of  this  mineral_,  placed  in  the  bottom  of  a  cavity  in  a  tooth 
previously  to  filling,  will  effectually  prevent  irritation  of  the 
pulp  from  impressions  of  heat  and  cold.  The  cavity,  how- 
ever, should  be  first  properly  prepared,  washed  with  tepid 
water  and  made  perfectly  dry.  The  asbestos  may  occupy 
from  one-fourth  to  one-sixth  of  the  depth  of  the  cavity  after 
the  filling  has  been  introduced  and  consolidated. 

A  thin  layer  of  gutta  percha  placed  in  the  bottom  of  the 
cavity,  previously  to  introducing  the  gold,  is  as  effectual  in 
preventing  the  transmission  of  impressions  of  heat  and  cold, 
as  asbestos,  and  can  be  more  conveniently  applied.  There  is, 
however,  a  preparation  of  it,  known  as  "Hill's  stopping," 
better  than  the  simple  article.  The  method  of  applying  it 
is  very  simple.  The  cavity  being  first  properly  prepared,  a 
a  small  piece  of  this  preparation  is  slightly  warmed  by  a 
fire,  or  by  the  flame  of  a  candle  or  lamp,  tlien  placed  in  the 
bottom  of  the  cavity  and  adapted  to  its  inequalities  by  press- 
ing on  it  gently  with  a  large  broad-pointed  plugger.  This 
done,  the  cavity  may  be  filled  with  gold  in  the  usual 
manner. 

Cork^  though  an  equally  good  non-conductor  of  caloric,  is 
thought  by  some,  as  it  is  more  destructible  than  asbestos  or 
gutta  percha,  to  be  objectionable,  but  cutoff,  as  it  necessarily 
would  be  in  the  bottom  of  the  cavity  beneath  the  filling,  its 
liability  to  undergo  any  change,  would  seem  to  be  rendered 
wholly  impossible.  The  only  valid  objection  to  its  use,  is, 
that  it  is  of  a  more  porous  nature  than  gutta  percha,  and  can- 
not be  adapted  as  perfectly  to  the  inequalities  of  the  floor  of 
the  cavity.    In  consequence  of  this^  there  is  danger  in  intro- 


DISEASES   OF   THE   DENTAL   PULP   AND    PERIOSTEUM.         463 

ducing  the  filling  of  forcing  some  portions  of  the  gold 
through  it,  unless  a  very  thick  piece  be  used.  Oiled  silk 
has  also  been  used  in  some  cases  very  successfully,  but  it  is 
not  as  good  a  non-conductor  as  any  of  the  before-mentioned 
agents. 

But  a  metallic  filling  is  not  the  only  medium  through 
which  impressions  of  heat  and  cold  are  conveyed  to  the 
dental  pulp.  When  the  dentine  on  the  coronal  extremity 
or  side  of  a  tooth  becomes  very  thin  from  loss  of  substance, 
occasioned  either  by  mechanical  or  spontaneous  abrasion,  the 
use  of  the  file,  erosion,  or  other  cause,  the  pulp  sometimes 
becomes  painfully  affected  by  the  action  of  these  agents. 
Loss  of  substance  from  any  of  these  causes,  is  also  often  at- 
tended by  exalted  sensibility  of  the  exposed  dentine  ;  and 
when  this  is  the  case,  the  contact  of  acids  with  it  is  produc- 
tive of  more  or  less  pain.  Nature,  however,  usually  em- 
ploys means  to  prevent  the  painful  consequences  that  would 
naturally  arise  from  continued  abrasion  of  the  coronal  ends 
of  the  teeth  and  the  consequent  exposure  of  their  nervous 
pulp,  consisting  in  the  gradual  ossification  of  this  organ, 
so  that  by  the  time  it  would  become  exposed,  it  is  converted 
into  osteo-dentine.  But  this  does  not  always  take  place  in 
time  to  prevent  irritation  and  pain. 

When  irritation  of  the  pulp  occurs  in  a  tooth  that  has 
been  filed  on  one  or  both  sides,  so  much  so  as  to  leave  only  a 
thin  covering  of  dentine,  the  best  known  means  of  prevent- 
ing morbid  sensibility  is,  to  keep  the  filed  surface  constantly 
clean  by  frequent  friction,  both  with  a  brush  and  waxed 
floss  silk,  or  some  other  suitable  substance.  This  operation 
should  be  repeated  after  each  meal,  and  in  the  morning  im- 
mediately after  rising,  and  at  night  before  going  to  bed. 

When  caries  has  extended  to  the  central  cavity,  irritation 
is  often  produced  by  contact  of  partially  decomposed  portions 
of  dentine  or  other  foreign  matter  with  the  pulp.  The 
proper  remedial  indication  in  such  cases,  it  is  scarcely  neces- 
sary to  say,  consists  in  the  removal  of  whatever  matter  from 
the  tooth  that  can  act  either  as  mechanical  or  chemical  irri- 


/ 


464  INFLAMMATION   OF  THE  DENTAL  PULP. 

tants.  This  done,  the  cavity  in  the  tooth — supposing  the 
pul])  to  he  in  a  healthy  condition — should  be  properly 
filled. 

But  when  the  irritation  arises  as  a  consequence  of  exalted 
irritability  and  increased  vascular  action  of  the  pulp,  de- 
pendent upon  disease  or  altered  function  of  some  other  part 
or  parts  of  the  body,  the  remedial  indications  are  different. 
The  treatment .  then  shoulii .  be  -  addressed  to  the  primary 
affection.  Examples  of  this  sort  are  of  frequent  occurrence. 
They  are  met  with  almost  daily,  particularly  in  females 
during  gestation,  and  in  dyspeptic  individuals,  and  persons 
affected  with  gout  and  chronic  rheumatism.  They  are  also 
sometimes  met  with  in  individuals  who  have  been  exposed 
to  miasmatic  emanations  of  marshy  districts,  when  the  irri- 
tation assumes  an  intermittent  form,  occurring  at  stated  in- 
tervals of  twenty-four,  forty-eight  or  seventy-two  hours,  and 
continuing  from  one  to  three  hours.  Some  of  the  worst 
forms  of  tooth-ache  are  produced  by  one  or  other  of  these 
causes. 

The  local  disturbance,  when  it  occurs  in  females  during 
pregnancy,  may  generally  be  removed  by  mild  aperients, 
warm  foot-bath  and  anodynes  at  night  on  going  to  bed. 
When  it  depends  upon  other  kinds  of  derangement  of  the 
uterine  organs^  treatment  suited  to  the  peculiar  indications 
of  the  case  should  be  instituted.  When  it  occurs  in  a  person 
affected  with  dyspepsia,  rheumatism  or  gout,  the  constitu- 
tional treatment  required  by  the  particular  disease,  consti- 
tutes the  proper  remedial  indication.  When  the  irritation 
assumes  an  intermittent  form,  an  emetic  or  cathartic,  fol- 
lowed by  quinine,  will  gcnerall}'  put  a  stop  to  the  local  dis- 
turbance, provided  it  has  no  connection  with  caries  of  the 
crown  of  the  tooth, 

INFLAMMATION. 

The  pulp  of  a  tooth,  when  healthy,  has  a  grayish -white 
appearance,  and  its  cai^illaries  are  invisible  to  the  naked  eye, 


INFLAMMATION  OF  THE  DENTAL  PULP.        465 

but  when  it  becomes  the  seat  of  acute  or  active  inflammation, 
they  may  be  distinctly  seen — the  organ  having  assumed  a 
bright  red  color.  Inflammation  having  established  itself, 
soon  extends  to  every  part  of  the  pulp,  and  even  to  the 
alveolo-dental  periosteum.  When  permitted  to  run  its 
course  uninterruptedly,  it  usually  terminates  in  suppuration 
in  from  three  to  eight  or  ten  days. 

The  unyielding  nature  of  the  walls  of  the  cavity  in  which 
it  is,  on  all  sides,  enclosed,  renders  expansion  of  the  pulp 
impossible,  and  as  its  capillaries  become  distended  with 
blood,  they  press  on  the  nervous  filaments  which  are  every- 
where distributed  upon  it,  causing  at  first  constant  gnaiving, 
but  afterwards,  as  the  distention  of  the  vessels  increases, 
severe,  and  sometimes  almost  insupportable,  deep-seated 
throhbing  pain. 

Inflammation  may  attack  the  pulps  of  sound  teeth  as  well 
as  those  affected  with  caries,  but  it  occurs  more  frec][uently 
in  the  latter  than  in  the  former,  and  it  is  oftener  met  with 
before  than  after  the  pulj)  has  become  actually  exposed. 
The  severity  of  the  pain,  however,  is  determined  by  the 
condition  of  the  tooth,  the  state  of  the  general  health,  and 
the  causes  concerned  in  its  production.  The  pulp,  when  in 
an  irritable  condition,  is  more  liable  to  become  the  seat  of 
acute  inflammation  than  when  in  a  perfectly  healthy  state, 
and  the  occurrence  of  suppuration  is  soon  followed  by  al- 
veolar abscess,  unless  an  opening  is  made  immediately 
through  the  crown,  neck  or  root  of  the  tooth  for  the  escape 
of  the  matter. 

The  efl'usion  of  lymph  which  takes  place  during  the  in- 
flammatory stage,  and  which,  under  other  circumstances, 
and  when  the  inflammation  is  less  severe,  is  made  to  play 
an  important  part  in  the  reparation  of  the  injury,  compress- 
es the  pulp  into  still  narrower  limits  as  it  accumulates  in 
quantity,  and,  thus,  becomes  an  additional  source  of  irri- 
tation, adding  fuel  to  the  flame  already  lighted  up. 

Inflammation  of  the  pulp  may  be  caused  by  a  blow  on 
the  tooth  ;  by  impressions  of  heat  and  cold  conveyed  to  it 


466  INFLAMMATION   OF   THE  DENTAL   PULP. 

througli  the  conducting  medium  either  of  the  enamel  and 
dentine,  or  a  metallic  filling,  or  hj  the  pressure  of  a  fill- 
ing, or  the  direct  contact  of  external  irritating  agents,  as 
disorganized  portions  of  the  tooth,  particles  of  alimentary 
substances,  acrid  humors,  etc.  But,  as  we  have  stated  in 
another  place,  inflammation  of  the  dental  pulp  "is  not  al- 
ways a  necessary  consequence  of  impressions"  of  heat  and 
cold  ;  pain  may  be  produced  by  them  when  it  does  not  ex- 
ist, but  in  this  case  it  usually  subsides  soon  after  the  re- 
moval of  the  irritant.  The  pulp  of  a  tooth  may  be  exposed 
for  months,  and  subjected  several  times  a  day  to  the  actual 
contact  of  foreign  bodies,  without  becoming  the  seat  of  acute 
inflammation.  The  irritation  and  increased  vascular  action 
thus  occasioned,  are,  no  doubt,  removed  by  the  effusion  of 
lymph  to  which  they  give  rise,  and  the  pulp,  after  it  has  be- 
come exposed,  having  room  to  expand  as  its  vessels  become 
distended,  does  not  suffer  irritation  from  the  pressure  to 
which  it  would  otherwise  be  subjected. 

When  suppuration  takes  place,  the  pain  very  nearly 
ceases,  but  the  tooth  for  a  time  remains  sore  to  the  touch, 
and  its  appearance  is  changed.  It  has  no  longer  the  pecu- 
liar animated  translucency  of  a  living  tooth,  but  lias  assum- 
ed an  opaque,  muddy  or  brownish  aspect.  With  the  disor- 
ganization of  the  pulp,  the  entire  crown  and  inner  walls  of 
the  root  lose  their  vitality;  still,  if  the  alveolo-dental  perios- 
teum has  not  become  seriously  involved  in  disease,  the  vas- 
cular and  nervous  supply  furnished  the  exterior  of  the  root, 
is  often  sufficient  to  prevent  the  tooth  from  exerting  a  mani- 
festly obnoxious  influence  upon  the  surrounding  and  more 
highly  vitalized  parts.  The  cementum  being  more  anala- 
gous  in  structure  to  true  osseous  tissue  than  dentine,  now 
plays  an  important  part  in  the  animal  economy.  It  being 
more  liberally  supplied  with  the  nutritive  juices  and  vi- 
tality, and  not  being  sensibly  afiected  by  the  death  of  the 
other  parts  of  the  organ,  it  keeps  up  the  living  relationship 
of  the  tooth  with  the  alveolo-dental  periosteum,  at  least  suf- 
ficiently to  prevent  it  from  acting  perceptibly  as  a  morbid 
irritant. 


INFLAMMATION  OF  THE  DENTAL  PULP.        467 

Inflammation  of  the  pulp  of  a  tooth,  besides  the  local 
pain  with  which  it  is  attended,  often  gives  rise  to  a  train  of 
constitutional  morbid  phenomena,  usually  of  a  mild_,  but 
sometimes  of  an  aggravated  and  even  threatening,  charac- 
ter. Among  these  are  head-ache,  constipation  of  the  boivels, 
furred  tongue,  dryness  of  the  sJcin,  quick,  full  and  hard  pulse, 
ear-ache,  optlialmia,  disease  of  the  maxillary  sinus,  etc. 

The  amount  of  constitutional  disturbance  arising  from  in- 
flammation of  the  pulp  of  a  tooth,  depends  on  the  state  of 
the  general  health,  and  the  nervous  irritability  of  the  sys- 
tem at  the  time.     In  the  majority  of  cases  it  occasions  but 
little  inconvenience,  and   disappears  as  soon  as  the  inflam-  \rTt\>.i) 
mation  ceases,  but  sometimes  it  assumes  a  very  alarming  ' 
character.     A  case  of  fatal  tetanus,  produced  by  inflamma-  Cai^^F  Q  . 
tion  of  the  pulji  of  a  lower  molar,  occurred  a  few  years  ago  .^  j- 1^  /^^^^ 
in  Baltimore.    The  subject  was  a  young  lady  about  eighteen        ;yy .    qj 
years  of  age.     The  system,  at  the  time,  from  great  bodily 
fatigue  and  mental  excitement,  was  in  an  exceedingly  irri-    ^    " 
table  condition,  but  in  other  respects,  though  constitutional- 
ly rather  delicate,  she  was  in  the  enjoyment  of  good  health. 

There  is  not  an  organ  or  tissue  of  the  body  in  whicb 
acute  inflammation  is  more  intractable  in  its  nature,  and 
rapid  in  its  progress,,  than  in  the  pulp  of  a  tooth  ;  and, 
when  we  take  into  consideration  its  situation,  and  physical 
and  vital  peculiarities,  it  is  not  to  be  wondered  that  it 
should,  in  so  large  a  majority  of  the  cases,  terminate  in  the 
disorganization  of  the  part.  Still  it  may  sometimes  be  ar- 
rested, and  the  remedial  indications  here,  though  they  can- 
not be  as  readily  and  fully  carried  out,  are  the  same  as  for 
inflammation  in  any  other  part  of  the  body.  The  first  and 
most  important  one  consists  in  the  removal  of  all  local  and 
exciting  causes.  If  it  be  the  result  of  irritation  produced 
by  the  pressure  of  a  filling,  the  plug  should  be  immedi- 
ately removed,  leeches  api)]ied  to  the  gum  of  tlie  afiected 
tooth,  and,  if  the  patient  be  of  a  full  habit,  blood  may 
be  taken  from  the  arm,  and  a  brisk  saline  purgative  pre- 
scribed.    The  removal  of  the  filling,  however,   when  the 


468         INFLAMMATION  OF  THE  DENTAL  PULP. 

inflammation  lias  previously  made  much  progress,  will  not 
prevent  suppuration,  but  it  may  prevent  it  from  extending 
to  every  part  of  the  pulp.  When  an  external  opening  is 
made  for  the  escape  of  the  matter  the  moment  suppuration 
takes  place,  the  remaining  portion  of  the  pulp  will  be  re- 
lieved from  pressure,  the  cause  of  the  irritation,  and  then 
the  inflammatory  action  may  cease.  But  if  the  matter  re- 
mains in  the  central  cavity  of  the  tooth,  the  part  of  the  pulp 
which  has  not  suppurated  will  still  be  subjected  to  pressure, 
and  the  inflammation  and  suppuration  will  go  on  until  the 
entire  organ  perishes.  Nor  will  the  disorganizing  process 
stop  here.  The  alveolo-dental  membrane,  at  the  extremity 
of  the  root,  will  soon  become  implicated,  and  in  a  short 
time  alveolar  abscess  will  form,  thus  terminating  the  acute 
stage  of  the  disease. 

There  may  be  no  indications  of  irritation  or  inflamma- 
tion for  several  weeks,  or  even  months,  after  a  tooth  has 
been  filled,  but  at  the  expiration  of  this  time,  the  pulp, 
from  increased  irritability,  caused,  perhaps,  by  some  change 
in  the  state  of  the  patient's  general  healthy  may  be  attacked 
by  inflammation.  Although  this  verj-  seldom  happens,  it 
does,  nevertheless,  sometimes  occur,  and,  when  there  is  rea- 
son to  apprehend  that  it  is  about  to  take  place,  a,nd  it  may 
be  suspected  if  pain  is  felt  in  the  tooth  when  anything  hot 
or  cold  is  taken  into  the  mouth,  or  if  it  becomes  the  seat  of 
gnawing  or  gradually  increasing  pain,  the  filling  should  be 
moved.  If  the  pain  now  ceases,  a  thick  layer  of  gutta  per- 
cha^  or  ''Hill's  stopping,"  may  be  placed  in  the  bottom  of 
the  cavity,  and  the  filling  replaced,  using  the  precaution, 
as  before  directed,  to  introduce  the  gold  in  such  a  way  as  to 
prevent  the  liability  of  depressing  the  floor  of  the  cavity. 
But  if  the  pain  and  inflammation  continues  unabated, 
it  may  be  necessary  to  extract  the  tooth,  or  expose  the  pulp 
and  destroy  its  vitality  by  applying  to  it  some  powerful  es- 
charotic,  as  arsenious  acid,  which,  acting  more  promptly 
and  with  more  certainty  than  any  other,  seems  best  adapted 
to  the  purpose.     When  this  is  done,  it  is  usually  with  the 


I 


INFLAMMATION  OF  THE  DENTAL  PULP.         469 

view  of  securing  tlie  retention  and  preservation  of  the  tooth 
by  filling  the  pnlp-cavity  and  root,  an  operation  now  very 
frequently  performed  by  many  dentists. 

The  abstraction  of  blood  directly  from  the  pulp,  one 
would  suppose,  would  be  better  calculated  to  arrest  the  in- 
flammation than  almost  any  other  treatment,  but  we  do  not 
think  this  has  been  resorted  to  for  this  purpose  sufficiently 
often  to  determine  the  amount  of  therapeutic  agency  it  is 
cai)able  of  exerting.  At  any  rate,  it  seems  reasonable  to 
suppose  that  if,  by  this  means,  the  congestion  of  the  capil- 
laries could  be  removed,  the  tumefied  pulp  would  be  re- 
duced to  its  natural  size,  and  be  relieved  from  the  pressure 
to  which,  as  a  consequence  of  its  distended  condition,  it  is 
subjected.  To  obtain  the  largest  amount  of  benefit  capa- 
ble of  being  derived  from  the  operation_,  the  puncture 
should  be  made  in  that  portion  where  one  of  the  principal 
arteries  would  be  most  likely  to  be  punctured,  and  this,  it 
seems  to  us,  would  be  just  where  the  canal  of  the  root  en- 
ters the  chamber  of  the  crown  of  the  tooth.  But  in  mak- 
ing the  puncture  here,  the  pulp  being  very  small  at  this 
point,  there  is  danger  of  cutting  it  off,  and  as  reunion 
would  scarcely  be  likely  to  take  place,  the  portion  in  the 
central  cavity  would  necessarily  perish. 

If  the  pulp  were  exposed,  there  would  be  a  better  oppor- 
tunity of  relieving  the  congested  condition  of  its  capillaries 
by  the  abstraction  of  blood,  but  the  difficulty  of  obtaining 
free  access  to  the  organ  by  drilling  a  hole  through  the  in- 
tervening dentine  is  so  great,  the  tooth,  when  suffering 
from  inflammation,  being  usually  so  sore  to  the  touch  that 
the  slightest  pressure  is  productive  of  great  pain,  hence,  the 
operation  will  seldom  if  ever  prove  successful.  Unless, 
therefore,  the  retention  of  the  tooth  is  a  matter  of  more 
than  ordinary  importance,  it  is  better  to  remove  it  at  once. 
But  if  it  is  an  incisor  or  cuspid,  the  pulp  should  be  imme- 
diately extirpated  or  arsenious  acid  applied  for  the  destruc- 
tion of  its  vitality  ;  or,  if  suppuration  has  previously  taken 
place,  an  opening  should  be  made  into  the  chamber  of  the 


r 
'v. 


4Y0         INFLAMJMATION  OF  THE  DENTAL  PULP. 

tooth  as  before  directed,  for  the  escape  of  the  matter. 
Shoukl  it  be  found,  after  this  has  escaped,  that  disorganiza- 
tion has  not  extended  to  every  part  of  the  pulp,  the  remain- 
ing portion  may  be  destroyed  in  the  manner  as  above  de- 
scribed. This  done,  the  pulp-cavity  and  root,  as  soon  as 
the  inflammation  of  the  socket  has  completely  subsided, 
may  be  filled. 

It  will  be  seen  from  the  foregoing  remarks,  that  it  is  only 
at  its  very  inception,  that  there  is  any  chance  of  combating 
successfully  acute  inflammation  of  the  pulp  of  a  tooth_,  and 
even  then,  so  rapid  is  the  progress  of  the  disease,  it  may 
baflle  the  best  directed  and  most  energetic  treatment,  that 
can  be  adojjted.  It  may  be  that  when  attention  shall  have 
become  more  generally  directed  to  the  subject,  that  some 
more  successful  method  of  treatment  may  be  discovered,  but 
that  a  complete  mastery  over  the  disease  will  ever  be  ob- 
tained, is  not  to  be  expected. 

But  inflammation  of  the  dental  pulp  is  not  always  acute ; 
it  sometimes  assumes  a  chronic  and  local  form.  This  often 
occurs  where  the  chamber  of  a  tooth  has  become  gradually 
exposed  by  caries  of  the  dentine,  and  when  this  happens, 
the  action  of  the  fluids  of  the  mouthy  and  other  foreign 
substances  which  obtain  access  to  the  cavity,  as  well  as  the 
decomposed  portions  of  the  tooth  substance,  cause  an  in- 
crease of  vascular  action  in  the  exposed  part,  followed,  very 
often,  by  a  slight  discharge,  but  the  morbid  action  thus  in- 
duced is,  comparatively,  seldom  accompanied  by  pain.  The 
pulp  may  remain  thus  partially  exposed  for  months,  and 
even  years,  without  causing  any  other  inconvenience  than  a 
momentary  twinge  of  pain  when  some  hard  substance  is  ac- 
cidentally introduced  into  the  cavity  of  the  tooth,  which  sub- 
sides immediately  after  its  removal.  Sooner  or  later,  how- 
ever, the  pain  thus  excited  will  become  more  permanent, 
continuing  each  time  it  is  produced^  from  five  or  ten  min- 
utes to  one  or  more  hours  after  the  cause  of  the  irritation 
has  been  removed.  If  a  tooth  be  filled  under  such  circum- 
stances, the  pressure  of  the  fluid  upon  the  pulp_,  which  is 


INFLAMMATION   OF   THE  DENTAL  PULP.  471 

poured  out  from  its  exposed  surface  beneath  the  plug,  will 
give  rise  to  a  more  general  and  active  form  of  inflammatory 
action. 

The  liability  of  the  tooth  to  ache  increases  as  the  pulp 
becomes  more  and  more  exposed  by  the  gradual  decomposi- 
tion of  the  dentine^  and  the  inflammation  may  ultimately 
assume  a  more  active  form,  or  the  pulp  may  become  the  seat 
of  fungous  growth,  or  be  absorbed  or  destroyed  by  ulcera- 
tion, or  gangrene  and  mortification.  Cases  sometimes  occur 
in  which  the  disease  is  attended  with  severe  darting  pains, 
occurring  very  often,  several  times  in  the  space  of  two  or 
three  minutes,  succeeded  by  intervals  of  perfect  ease  for  as 
many  hours.  At  other  times  it  is  attended  by  dull  aching 
pain,  aggravated  by  taking  sweet  or  acid  substances  into 
the  mouth.  In  cases  of  this  sort,  the  application  of  heating 
or  stimulating  substances  to  the  exposed  surface  of  the  pulp 
will  usually  procure  relief.  Permanent  exemption  from 
pain,  however,  is  rarely  obtained,  and  sooner  or  later,  it 
becomes  necessary  either  to  destroy  the  pulp  or  to  extract 
the  tooth. 

The  body  of  the  pulp  when  the  organ  becomes  exposed 
from  a  decayed  opening  in  the  grinding  surface  of  a  molar, 
is  sometimes  absorbed,  while  the  prolongations  in  the  roots 
often  remain  unchanged  for  two,  three  or  more  years. 

Chronic  inflammation  of  an  exposed  surface  of  the  pulp, 
when  long  continued  sometimes  give  rise  to  ulceration — a 
disorganizing  process,  which  often  causes  the  destruction  of 
a  large  portion  of  the  part  occupying  the  central  chamber  of 
the  crown  of  the  tooth,  making  in  it  numerous  little  exca- 
vations. The  ulcerated  surftice  usually  presents  a  yellowish 
appearance,  and  when  the  disorganizing  process  is  arrested 
before  it  has  efiected  the  destruction  of  a  very  large  portion 
of  the  pulp,  usually  becomes  covered  with  healthy  granula- 
tions. 

When  the  inflammation  occurs  in  cachectic  individuals  it 
often  assumes  an  acute  form,  and  sometimes  terminates  in 
gangrene  and  mortification.     The  loss  of  vitality  may  be 


472         INFLAMMATION  OF  THE  DENTAL  PULP. 

confined  to  the  body  of  the  pulp,  or  it  may  extend  to  eveiy 
part  of  the  organ.  In  the  former  case  the  pain  continues, 
hut  in  the  latter  it  ceases  as  soon  as  mortification  takes 
place.  When  this  happens,  the  entire  pulp^  which  has  now 
a  dark  brown  or  black  color,  may  be  removed.  But  this  is 
not  a  very  common  termination. 

The  symptoms  of  chronic  as  well  as  acute  inflammation 
are  always  modified  by  the  state  of  the  general  health,  hab- 
it of  body,  and  the  temperament  of  the  individual.  The 
pain  attending  the  former,  however,  is  periodical,  occurring 
at  irregular  and  uncertain  intervals,  aad  constitutes  that 
variety  of  tooth-ache  so  often  relieved  by  local  applications, 
whereas,  in  the  latter,  it  is  constant. 

In  chronic  inflammation,  the  pulp  is  either  actually  ex- 
posed or  only  covered  by  decomposed  or  partially  decom- 
posed dentine,  and  the  diseased  surface,  rarely  embraces  a 
larger  circumference  than  that  described  by  the  bottom  of  the 
decayed  cavity.  The  inflammation,  therefore,  is  local  as  well 
as  chronic,  but,  nevertheless,  it  is  often  of  so  persistent  a 
character,  as  to  render  its  removal  exceedingly  difficult. 
The  dentist,  however,  is  not  so  much  restricted  in  the  ap- 
plication of  remedies  as  in  the  treatment  of  acute  inflamma- 
tion, and  to  the  action  of  which  it  yields  more  readily. 
But  notwithstanding  all  this,  he  will  necessarily  encounter 
difficulties  in  his  efibrts  to  subdue  it.  A  greater  length  of 
time  is  sometimes  recj[uired  than  the  patient  is  willing  to 
give,  and  the  opening  through  the  crown  to  the  central  cav- 
ity is,  not  unfrequently,  too  small,  previously  to  the  remov- 
al of  the  partially  decomposed  dentine,  to  admit  of  the  di- 
rect application  of  the  necessary  remedial  agent  to  the  in- 
flamed surface  of  the  pulp.  Again,  it  often  happens,  that 
the  situation  of  the  tooth  and  cavity  are  such  as  to  prevent 
him  from  abtaining  a  complete  view  of  the  diseased  part, 
and  it  is  important  that  he  should  do  this  to  enable  him  to 
determine  whether  the  inflamed  surface  is  ulcerated,  or  pours 
out  a  serous  fluid,  or  whether  the  morbid  condition  consists 
merely  of  irritation,  produced  by  the  presence  of  acrid  mat- 


INFLAMMATION   OF  THE  DENTAL  PULP.  473 

ter,  or  of  partially  or  wholly  decomposed  dentine.  Unless 
his  diagnosis  is  correct,  his  prescription  will  be  as  likely  to 
do  harm  as  good.  But,  having  ascertained  the  exact  char- 
acter of  the  disease,  he  may  often  be  able  to  institute  treat- 
ment that  will  result  in  the  restoration  of  the  pulp  and  the 
preservation  of  the  tooth. 

It  is  important,  too,  to  understand  the  part  which  nature 
plays  in  the  curative  process,  for  cure  here,  as  in  the  case  of 
the  cure  of  disease  in  other  parts  of  the  body,  is  effected  by 
that  internal  force,  which,  as  Chomel  says,  '''presides  over 
all  the   phenomena   of  life,  contends  unremittingly  with 
physical  and  chemical  laws,  receives  the  imj)ression  of  dele- 
terious agents,  reacts  against  them  and  effects  the  resolution 
of  disease."     This  vital  force  is  sometimes  efficiently  exer- 
cised in  the  cure  of  disease  in  the  pulp  of  a  tooth,  but  more 
frequently  in  its  prevention,  as  is  shown  by  the  gradual  os- 
sification of  the  organ  in  those  cases  where  it  would  other- 
wise become  exposed  by  mechanical  or  spontaneous  abrasion 
of  the  solid  structures  which  enclose  it,  and  occasionally  by 
the  formation  of  secondary  dentine   upon  its  surface  at  a 
point  towards  which  the  caries  is  advancing.     Nature,  no 
doubt,  would  always  provide  in  this  way  against  the  expo- 
sure of  the  pulp,  if  the  occurrence  was  always  preceded  for  a 
sufficient  length  of  time  to  enable  her  to  do  so,  by  sufficient 
irritation  or  increase  of  vascular  action  in  it  to  call  her  en- 
ergies into  operation.     But  the  formation  of  osteo-dentine, 
which  constitutes  the  protective  wall  of  defence,  is  a  tardy 
process,  and  as  a  general  rule,   proceeds  more  slowly  than 
the  caries  in  the  tooth,  which   causes  the  exposure  of  the 
pulp.     Besides  it  often  happens  that  its  approach  is  not  an- 
nounced by  the  slightest  irritation,    a  condition  necessary 
to  the  new  formation,  until  it  reaches  the  central  cavity.     At 
other  times,  the  approach  of  the  disease  gives  rise  to   too 
much  irritation,  a  condition  equally  unfavorable  to  the  den- 
tinification  of  the  pulp.     Thus  no  protective  covering  being 
formed,  it  soon  becomes  exposed,  when  it  is  subjected  to  the 
action  of  such  irritating  agents  as  may  chance  to  be  brought 
31 


474  INFLAMMATION   OP  THE  DENTAL  PULP. 

into  contact  with  it.  Hence,  its  liability  to  become  the  seat 
of  chronic  inflammation  as  well  as  other  forms  of  diseased 
action. 

If  the  disease  is  attended  with  pain,  the  removal  of  this 
should  first  claim  attention,  and  this  should  be  effected  with 
as  little  delay  as  possible,  otherwise  the  morbid  action  may 
extend  to  every  part  of  the  pulp  and  peridental  membrane, 
and  assume  a  more  active  and  unmanageable  form.  If  the 
pain  is  the  result  of  irritation  produced  by  the  direct  action 
of  mechanical  or  chemical  agents,  the  cavity  in  the  tooth 
should  at  once  be  carefully  freed  from  all  extraneous  sub- 
stances and  decomposed  portions  of  dentine.  This  done,  a 
dossil  of  raw  cotton  or  lint,  saturated  with  spirits  of  cam- 
phor^ laudanum,  sulphuric  ether,  chloroform,  creosote^  or 
some  one  of  the  essential  oils  may  be  applied.  Immediate 
relief  is  sometimes  obtained  by  an  application  of  this  sort. 
Counter-irritants  have  sometimes  been  used  with  advantage. 
The  pain  has  often  been  removed  by  exciting  increased  se- 
cretion of  saliva,  but  when  a  sialagogue  is  used,  the  cavity 
in  the  tooth  should  be  filled  with  raw  cotton  or  lint  to  pre- 
vent the  agent  from  being  brought  in  contact  with  the  ex- 
posed surface  of  the  pulp.  But  a  remedy  which  will  relieve 
the  pain  in  one  case  often  aggravates  it  in  another. 

When  the  irritation  is  produced  by  acidulated  buccal 
fluids,  the  application  of  carbonate  of  soda  or  some  other 
alkali,  will  often  give  immediate  temporary  relief,  but  as  the 
condition  of  the  secretions  of  the  mouth,  especially  of  the 
salivary,  is  usually  owing  to  gastric  derangement,  the  cor- 
rection of  this  constitutes  the  first  and  most  important 
remedial  indication.  When  any  application  is  made  to  the 
pulp  for  the  purpose  of  removing  irritation  and  pain,  their 
full  effect  will  not  be  obtained  unless  the  fluids  of  the  mouth 
are  excluded  from  the  cavity  of  the  tooth,  and  this  may  be 
done  by  closing  the  orifice  with  softened  wax  or  mastic, 
using  the  precaution  not  to  force  it  in  so  far  as  to  press  the 
application  previously  made,  upon  the  exposed  pulp. 

Until  within  the  last  three  or  four  years,  the  writer  did 


SPONTANEOUS  DISORGANIZATION   OF  DENTAL  PULP.         475 

not  believe  it  possible  to  preserve  the  vitality  of  a  tooth  by 
filling,  after  the  pulp  had  become  the  seat  of  chronic  in- 
flammation, but  he  is  now  convinced  that  it  can  be  done  in 
very  many  cases,  but  to  effect  vp^hich  several  weeks  of  pre- 
paratory treatment  are  often  required. 

SPONTANEOUS  DISORGANIZATION. 

The  spontaneous  destruction  of  the  pulp  of  a  tooth  is  an 
affection  which  seems  to  have  been  entirely  overlooked  by 
writers  on  dental  pathology  ;  and,  although  it  is  one  which 
rarely  occurs,  examples  of  it  are  met  with  sufficiently  often 
to  entitle  it  to  a  place  among  the  diseases  of  the  teeth.  The 
first  case  which  attracted  the  attention  of  the  author  occurred 
in  1836,  and  he  has  subsequently  met  with  six  or  seven 
others  ;  in  each  of  which,  the  disorganization  had  been 
carried  on  so  insidiously,  that  neither  the  presence  of  disease 
nor  structural  alteration  was  suspected,  until  the  teeth  had 
assumed  a  dull  brownish  or  bluish  brown  appearance.  The 
death  of  the  pulp  had  not  been  preceded  in  any  of  these  cases 
by  the  slightest  indication  of  inflammatory  action.  It  had, 
apparently,  resulted  from  want  of  sufficient  vital  energy 
to  sustain  the  nutritive  function. 

The  sockets  of  the  affected  teeth,  in  the  cases  which  have 
fallen  under  the  observation  of  the  author,  were,  seemingly, 
in  a  healthy  condition — a  circumstance,  which,  when  we 
take  into  consideration  that  the  parts  at  the  extremity  of  the 
roots  were  exposed  to  the  action  of  the  disorganized  remains 
of  the  dental  pulps,  may  appear  somewhat  strange.  But 
this  may  have  been  owing,  partly,  to  diminished  excitability 
in  the  alveolo-dental  periosteum,  and,  partly,  to  the  small- 
ness  of  the  quantity,  and  the  innoxious  character  of  the 
matter  contained  in  the  central  cavities  of  the  teeth.  The 
gums  of  that  portion  of  the  alveolar  border  occupied  by  the 
affected  teeth,  had  a  pale,  grayish-purple  appearance,  but 
exhibited  no  indications  of  actual  disease.  They  were  as 
thin  and  their  margins  as  distinctly  festooned  here  as  in  any 


476       FUNGOUS  GROWTH  OF  THE  DENTAL  PULP. 

other  part  of  the  mouth.  In  some  of  the  cases  too,  the 
teeth  had  been  in  this  condition  for  seven  or  eight  years. 
On  perforating  the  crowns,  only  a  drop  of  dark  brown 
matter,  having  but  little  odor  and  about  the  consistence  of 
thin  cream,  escaped  from  the  pulp-cavity  of  each. 

In  all  the  cases  which  the  author  has  seen  of  this  most 
remarkable  affection,  the  loss  of  vitality  had  taken  place 
previously  to  the  twentieth  year  of  age,  and  according  to  his 
observations  upon  the  subject,  it  seldom  confines  itself  to  a 
single  tooth,  but  occurs  simultaneously  in  corresj)onding 
teeth.  The  pulps  of  several  usually  perish  at  about  the 
same  time.  In  the  first  case  to  which  his  attention  was 
called,  six  had  lost  their  vitality.  The  affection,  too,  seems 
to  be  principally  confined  to  the  incisors  and  cuspids,  and 
sound  teeth  appear  to  be  as  subject  to  it  as  those  which  are 
carious. 

Now,  as  the  disorganization  of  the  pulp,  in  cases  of  this 
sortj  is  not  the  result  of  inflammatory  action,  it  must  be  de- 
pendent upon  constitutional  rather  than  local  causes — upon 
some  peculiar  cachectic  habit  of  body,  in  which  the  function 
of  sanguinification  is  imperfectly  performed.  This  inference, 
too,  seems  to  be  fully  warranted  by  the  appearance  of  the 
subjects  in  all  the  cases  which  the  author  has  had  an  oppor- 
tunity of  examining.  Each  of  whom  was  characterized  by 
an  extremely  pale  and  slightly  bloated  aspect  of  counte- 
nance— indicating  serous  condition  of  blood. 

The  remedial  indications  in  cases  of  this  sort,  are  the 
same  as  in  necrosis  produced  by  inflammation  and  suppura- 
tion of  the  lining  membrane  and  pulp. 

FUNGOUS   GROWTH. 

The  pulp  of  a  tooth,  when  exposed  by  decay  of  the  crown- 
sometimes  becomes  the  seat  of  a  fungous  growth,  consti- 
tuting a  small  vascular  tumor.  These  morbid  growths  some- 
times attain  the  size  of  a  large  pea,  completely  filling  the 
cavity  made  in  the  crown  of  the  tooth  by  decay  ;  at  other 


OSSIFICATION   OF   THE  DENTAL  PULP.  47Y 

times  tliey  do  not  exceed  that  of  a  small  elderberry.  The 
former  have  little  sensibility,  and  bleed  freely  from  the 
slightest  injury  ;  the  latter  are  less  vascular,  but  are  nearly 
as  sensitive  as  the  pulp  in  a  healthy  state. 

It  often  hapi^ens  that  a  fungous  growth  of  the  gum  or 
dental  periosteum,  finding  its  way  through  an  opening  in 
the  side  of  the  neck  or  root  of  a  decayed  tooth,  appears  in 
the  central  cavity,  and  this  is  sometimes  mistaken  for  a  mor- 
bid growth  of  the  pulp.  Tumors  of  this  sort  usually  grow 
very  fast,  and  sometimes  attain  the  size  of  a  hickory  nut. 
They  are  exceedingly  vascular,  bleeding  profusely  when 
wounded,  and  are  soon  reproduced  after  removal.  The 
author  has  met  with  tumors  of  this  kind  which  had  origi- 
nated in  the  alveolo-dental  periosteum  of  the  extremity  of 
the  root. 

The  remedial  indication  in  such  cases  consists  in  the  re- 
moval of  the  tooth.  A  cure  cannot  be  effected  by  extirpating 
the  morbid  growth.  The  author  has  frequently  removed 
them  nearly  to  the  extremity  of  the  root,  but  they  have 
always  reappeared  in  a  few  days  or  weeks  after  the  opera- 
tion. But  even  if  a  return  of  the  disease  could  be  prevented, 
still  the  extraction  of  the  tooth  should  be  insisted  on,  as  all 
teeth  in  which  tumors  of  this  sort  are  situated,  are  morbid 
irritants,  and  cannot  remain  without  detriment  to  the 
health  of  the  parts  with  which  they  are  in  immediate 
connection. 

OSSIFICATION. 

Allusion  has  been  made,  several  times,  in  the  course  of 
this  work,  to  the  ossification  of  the  dental  pulp,  as  a  means 
emjiloyed  by  nature  to  prevent  the  exposure  of  this  most 
delicate  and  exquisitely  sensitive  structure.  But  examples 
of  it  are  occasionally  met  with  in  teeth  which  have  suffered 
no  loss  of  substance,  either  from  mechanical  or  spontaneous 
abrasion,  or  from  the  decay  of  the  dentine.  The  occurrence, 
whatever  may  be  the  other  circumstances  under  which  it 
takes  place,  is  evidently  the  result  of  the  operation  of  an 


478  INFLAMMATION   OF  THE   DENTAL  PERIOSTEUM.  j 

Ij 

established  law  of  the  economy,  dependent  upon  moderate 
irritation  and  a  slight  increase  of  vascular  action,  and  ossifi-  '■ 
cation  having  commenced,  it  usually  goes  on  until  every 
part  of  the  pulp  is  converted  into  a  substance  analogous  to,  i 
if  not  identical  with,  cementum.  We  infer  then  that  when  j 
the  pulp  of  a  tooth  becomes  the  seat  of  a  sufficient  amount  ; 
of  irritation,  ossification  must  follow  as  a  necessary  conse-  \ 
quence,  but  if  the  irritation  be  succeeded  by  active  inflam-  j 
mation,  a  different  result  may  be  expected.  1 

The  irritation  necessary  to  the  ossification  of  ihe  pulp  of 
a  tooth  sometimes  arises  from  constitutional  causes,  but  in 
the  majority  of  cases^  it  results  from  the  action  of  local  irri- 
tants, and  most  frequently,  from  impression  of  heat  and 
cold,  communicated  through  the  conducting  medium  of  a 
metallic  filling  or  a  thin  layer  of  dentine. 

During  the  ossification,  a  sensation  is  occasionally  expe- 
rienced in  the  tooth  somewhat  similar,  though  altogether 
less  in  degree,  to  that  which  attends  the  knitting  of  the 
fi'actured  extremities  of  a  broken  bone.  A  numb,  vibratory 
pain,  barely  perceptible,  is  felt  passing  through  the  tooth 
several  times  a  day,  but  only  lasting  a  second  or  two  at  a 
time.  It  is  scarcely  sufiicient  to  occasion  any  annoyance,  or 
to  attract  anything  more  than  momentary  attention. 

With  the  ossification  of  the  pulp,  the  crown  and  inner 
walls  of  the  root  lose  their  vitality,  but  the  appearance  of  the 
tooth  is  not,  as  in  the  case  of  necrosis  arising  from  the  dis- 
organization of  the  pulp,  materially  affected.  The  central 
cavity  being  filled  with  semi-translucent  bone,  or  osteo-den- 
tine,  the  crown  retains  its  natural  color.  The  discoloration 
and  opacity  attending  necrosis  produced  by  other  causes,  re- 
mits, partly  from  the  presence  of  putrid  matter  in  the  pulp- 
cavity,  and  partly  from  its  absorption  by  the  surrounding 
dentinal  walls. 

INFLAMMATION  OP  THE  DENTAL  PERIOSTEUM. 

Inflammation  of  the  periosteum  of  a  tooth  may  be  acute 
or  chronic,  and  each  variety  may  be  modified  in  its  character 


INFLAMMATION  OP  THE  DENTAL  PERIOSTEUM. 


479 


Fig,  142. 


bofh  by  the  state  of  the  constitutional  health  and  the  causes 
concerned  in  its  production.  The  acute  variety,  when  left 
to  itself,  usually  terminates  in  alveolar  abscess,  but  the  sup- 
purative process  sometimes  extends  to  nearly  every  part  of 
the  periosteum,  causing  the  entire  death  of  a  toothy  and  of- 
ten followed  by  erosion  of  the  root,  and  necrosis  of  the  alve- 
olus. (See  Fig.  142.)  When  favored  by  a  cachectic  habit 
of  body,  it  often  extends  to  the  periosteum  of  the  jaw,  fol- 
lowed by  suppuration  and  necrosis.  Some  idea  may  be 
formed  of  the  severity  which  it  occasionally  assumes  by  the 
following  case. 

In  1840^  a  poor  girl,  aged  fourteen,  was  brought  to  the 
author.  About  three  months  before,  she  had  been  taken  to 
a  barber  tooth-drawer  for  the  purpose  of  having  the  first  left 
inferior  molar  extracted.  The  crown  was  broken  off,  the 
roots  left  in  the  socket.  Inflammation  supervened.  This 
soon  extended  to  the  periosteum  of  the  entire  bone  from  the 

second  bicuspid  to  the  cor- 
onoid  process,  and  as  it  was 
permitted  to  run  its  course 
uninterrupted,  it  termin- 
ated in  necrosis  and  exfo- 
liation of  all  this  i^ortion  of 
the  bone,  the  anterior  ex- 
tremity of  which,  at  the 
time  she  was  brought  to 
the  author,  had  passed  through  the  integuments  of  the  low- 
er part  of  the  face^  and  protruded  externally.  A  few  days 
after,  it  was  removed  without  difficulty.     See  Fig.  142. 

But,  as  the  causes,  symptoms  and  remedial  indications  of 
acute  inflammation  of  the  dental  periosteum  were  briefly 
described  in  the  chapter  on  tooth-ache,  and  as  we  shall  have 
occasion  to  refer  to  the  subject  again  when  we  come  to  treat 
of  alveolar  abscess,  it  will  not  be  necessary  to  dwell  uj)on  it 
here.  We  will  merely  state,  however,  that,  after  having 
terminated  in  suppuration,  it  sometimes,  instead  of  subsid- 
ing altogether,  degenerates  into  a  chronic  form,  and  when  fa- 


480  INFLAMMATION    OF   THE   DENTAL   PERIOSTEUM. 

vored  by  some  constitutional  vice,  as  the  scorbutic,  venereal 
or  scrofulous,  it  often  gives  rise  to  the  destruction  of  the 
socket  and  loss  of  the  tooth. 

Chronic  inflammation  of  the  dental  periosteum,  however, 
is  not  always  preceded  by  a  more  active  form  of  disease 
It  may  assume  this  form  at  the  commencement,  but  in  this 
case  it  is  complicated  with  tumefaction  of  the  gums  and  dis- 
charge of  puriform  matter  from  between  their  edges  and  the 
necks  of  the  teeth.  For  the  treatment  of  this  variety,  the 
reader  is  referred  to  chronic  inflammation  and  tumefaction  of 
the  gums. 


CHAPTER      TWENTY-FIRST. 

DISLOCATION  OF  THE  LOWER  JAW. 

From  the  peculiar  manner  in  wliicb.  tlie  inferior  maxilla 
is  articulated  to  tlie  temporal  bones,  it  is  not  very  liable  to 
be  dislocated,  and  when  one  or  both  of  its  condyles  are  dis- 
placed, the  luxation  is  always  forwards.  The  confirmation 
of  the  parts  prevents  it  from  taking  place  in  any  other  di- 
rection. The  oblong,  rounded  head  of  each  condyle  is  re- 
ceived into  the  fore  part  of  a  deep  fossa  in  the  temporal  bone, 
situated  just  before  the  meatus  auditorius  externus,  and  un- 
der the  beginning  of  the  zygomatic  arch.  The  articular 
surface  of  each  is  covered  with  a  smooth  cartilage,  and  be- 
tween which  there  is  a  movable  cartilage.  This  latter  is 
connected  with  tho  articulating  surface  of  the  condyle  and 
fossa  of  the  temporal  bone  by  ligaments  attached  to  its 
edges.  But  the  articulation  is  rendered  still  more  secure  by 
means  of  an  external  ligament  which  rises  from  the  exter- 
nal edge  of  the  fossa  in  the  temporal  bone,  and  is  attached 
to  the  neck  of  the  condyle  of  the  jaw,  which  it  surrounds — 
constituting  the  capsular  ligament.  The  intervening  mov- 
able cartilage,  from  being  more  strongly  connected  with  the 
head  of  the  condyle  than  to  the  articular  cavity,  escapes  with 
the  former,  whenever  dislocation  of  the  jaw  takes  place. 

Dislocation  of  the  lower  jaw  is  rarely  caused  by  a  blow, 
except  it  is  given  when  the  mouth  is  open  ;  it  is  more  fre- 
quently occasioned  by  yawning  or  laughing.  It  has  been 
known  to  occur  in  the  extraction  of  teeth,  and  in  attempting 
to  bite  a  very  large  substance.  Sir  Astley  Cooper  mentions 
the  case  of  a  boy  who  had  his  jaw  dislocated  by  suddenly 
putting  an  apple  into  his  mouth  to  keep  it  from  a  playfellow. 


482 


DISLOCATION   OF  THE  LOWER   JAW. 


After  the  jaw  has  been  dislocated  once,  it  will  ever  after 
be  more  liable  to  this  accident,  and  in  consequence  of  which 
Mr.  Fox  very  properly  recommends  to  those  to  whom  it  has 
once  happened,  the  precaution  of  supporting  the  jaw 
whenever  the  mouth  is  opened  very  widely  in  gaping,  or 
for  the  purpose  of  having  a  tooth  extracted.  But  none 
of  these  causes  would  be  sufficient  to  produce  the  acci- 
dent, except  the  ligaments  of  the  temporo-maxillary  artic- 
ulation are  very  loose,  and  the  muscles  of  the  jaw  very 
much  relaxed. 

The  author  has  never  had  an  opportunity,  in  his  own 
practice,  of  witnessing  but  one  case  of  dislocation  of  the 
lower  jaw,  and  the  subject  of  this  was  a  young  lady  from 
Virginia,  about  seventeen  years  of  age.  It  occurred  in 
attempting  to  extract  the  first  right  inferior  molar.  Both 
condyles  were  displaced,  but  so  completely  were  the  muscles 
of  the  jaw  relaxed,  that  he  immediately  reduced  it  without 
the  least  difficulty,  and  afterwards,  by  supporting  the  jaw 
with  his  left  hand. 

When  the  lower  jaw  is 
dislocated,  the  mouth  re- 
mains wide  open,  as  seen  in 
Fig.  143,  and  a  great  deal 
of  pain  is  experienced, 
which,  according  to  Boyer, 
is  caused  by  the  pressure  of 
the  condyles  on  the  deep- 
seated  temporal  nerves,  and 
those  which  go  to  the  mas- 
seter  muscles,  situated  at 
the  roots  of  the  zygomatic 
processes.  The  condyles 
having  left  their  place  of 
articulation,  are  advanced  before  the  articular  eminences 
and  lodged  under  the  zygomatic  arches.  The  jaw  cannot 
be  closed  ;  the  coronoid  processes  may  be  felt  under  the 
malar  bones  ;  the  temporal,  masseter  and  buccinator  mu8- 


succeeded  in  removing  the  tooth. 

FiQ.  U3. 


DISLOCATION   OF   THE  LOWER   JAW.  483 

cles  are  extended ;  the  articular  cavities  being  empty,  a  hol- 
low may  be  felt  there;  the  saliva  flows  uninterruptedly 
from  the  mouth,  and  deglutition  and  speech  are  either  wholly 
prevented,  or  very  greatly  impaired.  Boyer  says,  that 
'during  the  first  five  days  after  the  accident,  the  patient 
can  neither  speak  nor  swallow."  The  jaw,  when  only  one 
condyle  is  displaced,  is  forced,  more  or  less  to  one  side. 

If  the  dislocation  continues  for  several  days  or  weeks,  the 
chin  gradually  approaches  the  upper  jaw,  and  the  patient 
slowly  recovers  the  functions  of  speech  and  deglutition. 
We  are  told  by  Mr.  Samuel  Cooper,  that  it  may  prove  fatal 
if  it  remains  unreduced;*  but  Sir  Astley  Cooper  says,  he 
has  never  known  any  dangerous  effects  to  result  from  this 
accident — on  the  contrary,  that  after  it  had  continued  for 
i  considerable  length  of  time,  the  jaw  partially  recovered 
its  motion. t 

In  the  reduction  of  dislocation  of  the  lower  jaw,  the  an- 
cients employed  two  pieces  of  wood,  which  were  introduced 
in  each  side  of  the  mouth,  between  the  molar  teeth,  and 
while  they  were  made  to  act  as  levers  for  depressing  the 
back  part  of  the  bone,  the  chin  was  raised  by  means  of  a 
bandage. 

The  method  usually  adopted  by  surgeons  for  reducing  a 
dislocation  of  this  bone,  consists  in  introducing  the  thumbs, 
wrapped  with  a  napkin  or  cloth,  to  prevent  them  from  being 
hurt  by  the  teeth,  as  far  back  upon  the  molars  as  possible, 
then  depressing  the  back  part  of  the  jaw,  and  at  the  same 
time,  raising  the  chin  with  the  fingers.  In  this  way  the 
condyles  are  disengaged  from  under  the  zygomatic  arches, 
and  made  to  glide  back  into  their  articular  cavities.  But 
the  moment  the  condyles  are  disengaged,  the  thumbs  of  the 
operator  should  be  slipped  outwards  between  the  teeth  and 
cheeks,  as  the  action  of  the  muscles,  at  this  instant,  in" 
drawing  the  jaw  back,  causes  it  to  close  very  suddenly,  and 


*  Vide  Surgical  Dictionary,  p.  306. 

t  Vide  A.  Cooper  on  Dislocations,  p.  389: 


484  DISLOCATION   OF  THE  LOWER   JAW. 

witli  considerable  force^  so  that  this  precaution  is  necessaiy 
to  prevent  being  hurt,  unless  a  piece  of  cork  or  soft  wood 
has  been  previously  placed  between  the  teeth. 

By  the  foregoing  simple  method  of  procedure,  the  dislo- 
cation may  in  almost  every  case,  be  readily  reduced,  but 
Mr.  Fox  mentions  a  case  in  which  it  failed.  The  subject 
was  a  lady  who  had  had  her  lower  jaw  luxated  several  times 
before,  and  this  time  the  accident  was  occasioned  by  an  at- 
tempt which  he  made  to  extract  one  of  the  inferior  dentes 
sapientife.  After  having  failed  to  reduce  the  luxated  bone 
by  the  usual  method,  he  says,  he  '^'happened  to  recollect  a 
statement  made  to  him  by  M.  de  Chemant,  of  his  having 
been  frequently  applied  to  by  a  person  at  Paris,  who  was 
subject  to  this  accident,  and  that  he  always  succeeded  in 
reducing  the  luxation  immediately,"  by  means  ''of  a  lever 
of  wood,  as  recommended  by  Dr.  Monroe."  Profiting  by 
this  statement,  Mr.  F.  procured  a  piece  of  wood  "about  an 
inch  square,  and  ten  or  twelve  inches  long."  He  placed 
one  end  of  this  upon  the  lower  molars,  and  then  raised  the 
other,  so  that  the  upper  teeth  aided  as  a  fulcrum.  As  soon 
as  the  jaw  was  depressed,  the  condyle  of  the  side  upon 
which  the  wood  was  applied,  immediately  slipped  back  into 
its  articular  cavity.  The  wood  was  then  applied  to  the  op- 
posite side  of  the  jaw,  and  the  other  condyle  reduced  in  the 
same  manner.* 

The  method  proposed  by  Sir  Astley  Ci^oper,  consists, 
when  both  condyles  are  displaced,  in  introducing  two  corks 
behind  the  molars,  and  then  elevating  the  chin.  He,  how- 
ever, first  places  his  patient  in  a  recumbent  posture. f  But 
this  is  seldom  necessary.  The  reduction  of  the  dislocation 
can  be  as  conveniently  effected  with  the  patient  in  a  sitting 
as  in  a  recumbent  posture. 

•  After  the  reduction  of  the  dislocation,  the  patient  is  re- 
commended to  abstain  for  several  days  from  the  use  of  solid 


*  Vide  American  edition  of  Fox  on  the  Human  Teeth,  p.  330. 
t  Viddti..  Cooper  on  Dislocations,  p.  391. 


DISLOCATION   OF   THE   LOWER   JAW.  485 

aliments,  and  to  prevent  a  recurrence  of  tlie  accident,  to 
wear  a  four-tailed  bandage,*  or,  what  is  still  better,  the 
bandage  contrived  by  Mr.  Fox,  (see  Fig.  70,)  to  prevent  its 
recurrence  in  the  extraction  of  teeth.  When  it  is  used  for 
the  latter  purpose,  the  mouth  is  first  opened  to  a  proper  ex- 
tent, when,  with  the  condyles  in  their  articular  cavities,  it 
is  applied,  and  the  straps  tightly  buckled.  This  done,  it  is 
impossible  to  advance  the  jaw  sufiiciently  to  produce  a  dis- 
location. 

*  Vide  Cooper's  Surgical  Dictionary,  p.  306. 


1 


P^RT    FOTJETH. 


SALIVARY   CALCULUS. 

DISEASES   OF  THE   GUMS  AND  ALVEOLAR   PROCESSES, 

AND   THEIR   TREATMENT. 


I>A^RT     FOURTH. 


CHAPTER     FIRST. 

SALIVARY  CALCULUS, 

The  physical  cliaracteristics,  and  local  and  constitutional 
indications  of  salivary  calculus,  having  been  noticed  in  a 
preceding  place,  it  will  not  be  necessary  to  refer  to  them 
again.  We  shall,  therefore,  confine  our  remarks  chiefly  to 
its  elementary  constituents — its  origin — the  manner  of  its 
formation — its  effects,  and  the  removal  of  it  from  the  teeth. 


Fig.  144. 


Fig.  145. 


Tartar  or  salivary  calculus  sometimes  accumulates  in  very 
large  quantities,  giving  to  the  mouth  a  most  disagreeable 
and  repulsive  aspect,  and  imparting  to  the  breath,  not  un- 
frequently,  an  almost  insufferably  offensive  odor.  Fig.  144 
represents  a  set  of  teeth  encrusted  with  it,  and  Fig.  145  a 
single  tooth,  presented  to  the  author  by  Dr.  W.  Allen,  of 
Massachusetts,  with  the  largest  accumulation  of  this  sub- 
stance he  has  ever  seen  in  one  mass.  Its  longest  diameter 
is  an  inch  and  an  eighth^  its  shortest  seven-eighths,  and  its 
32 


490  CHEMICAL  CONSTITUENTS  OF  SALIVARY  CALCULUS. 

thickness  five-eighths  of  an  inch.  Imbedded  in  its  substan'.  <' 
is  the  entire  crown  and  neck  of  a  lower  dens  sapientae,  wliich 
was  removed  with  it.  It  is  of  a  light  brown  color,  and 
weighs  two  drachms  and  seventeen  grains. 

CHEMICAL  CONSTITUENTS  OP  SALIVARY  CALCULUS. 

Salivary  calculus  is  composed  of  phosphate  of  lime  and 
animal  matter,  combined  in  various  proportions,  according 
as  it  is  hard  or  soft,  consequently  no  two  analyses  will  yield 
the  same  result.     The  following  is  the  analysis  made  by  Mr 
Peps  for  Mr.  Fox.     Fifty  parts  yielded  : 

Phosphate  of  limCj       ....  35 

Fibrini,  or  cartilage,       ....  9 

Animal  fat,  or  oil,       ....  3 

Loss,       .......  3 


50 

Berzelius  gives  the  following  analysis.    He  found  one  hun- 
dred parts  to  contain 

Phosphate  of  lime  and  magnesia,  .  79.0 
Salivary  mucus  and  salivine,  .  .  13.5 
Animal  matter,         .         .         .         .  7.5 


Dr.  Dwindle,  dentist,  of  Cazenovia,  New  York,  furnishes 
the  following  : 

''Of  one  hundred  parts,  there  are,"  says  he,  ''of 

Phosphate  of  lime,      ....  60 

Carbonate  of  lime,          .         .         .  .14 

Animal  matter  and  mucus,           .         .  16 

Water  and  loss,            ....  10 

100" 


OEIGIN  AND   DEPOSITION   OF  SALrVART  CALCULUS.         491 

The  last  named  gentleman  acknowledges  that  he  could 
make  no  two  analyses  agree.  Hard  dry  tartar  contains  more 
earthy,  and  less  animal  matter  than  the  soft  humid  tartar. 

The  infusoria  of  which  M.  Mandl  says  tartar  is  composed, 
have  their  origin  in  the  vitiated  mucus  which  is  always 
mixed  with  it.  Scherer  detected  infusoria,  with  a  mi- 
croscope, in  the  saliva  of  a  girl  laboring  under  a  scorbutic 
affection  of  the  mouth,  in  large  numbers,  but  the  author  is 
inclined  to  believe  that  they  had  their  origin  in  the  mucous 
secretions  of  this  cavity,  which  are  always  mixed  with  the 
former  fluid.  They  are  more  or  less  numerous,  as  the  tartar 
is  hard  or  soft,  or  in  proportion  to  the  quantity  of  mucus 
that  enters  into  its  composition.* 

ORIGIN  AND  DEPOSITION  OF  SALIVARY  CALCULUS. 

There  exists  a  variety  of  opinions  with  regard  to  the 
source  from  whence  salivary  calculus  is  derived.  English 
and  American  writers  believe  it  to  be  a  deposit  from  the 
saliva_,  but  the  French  do  not  agree  concerning  its  origin. 
Jourdain  thinks  it  is  secreted  by  glands,  which  he  believes 
to  be  scattered  over  the  periosteum  of  the  teeth.  Grariot 
says  it  comes  from  the  gums.  Serres  tells  us  he  has  dis- 
covered upon  the  mucous  membrane  of  the  gums,  certain 
glands,  whose  particular  function  it  is  to  secrete  this  sub- 
stance. In  commenting  upon  the  views  of  this  last  men- 
tioned author,  M.  Delabarre  remarks  :  "The  small  glands, 
which  he  thus  designates,"  (alluding  to  the  appellation  of 
dental  which  tlie  author  gives  to  them,)  "may,  perhaps,  be- 
long to  the  mucous  or  salivary  system,  for  the  saliva,  as  all 
physiologists  know,  is  not  alone  furnished  by  the  parotid 
glands,  but  by  a  great  number  of  calculus  kennels  that  are 
very  observable  in  ruminating  animals,  scattered  over  various 
parts  of  the  mucous  membrane  of  the  mouth.  I,  therefore, 
am  of  opinion  that  this  is  a  gratuitous  supposition  on  the 

*  Dr.  Dwinelle  gives  a  minute  discription  of  their  appearance  in  the  1st  No. 
of  the  5th  volume  of  the  American  Journal  of  Dental  Science. 


492  ORIGIN   AND   DEPOSITION   OF   SALIVARY   CALCULUS. 

part  of  the  author,  because  children  of  a  very  early  age  are 
not  affected  with  tartar,  and  it  is  on  them  that  he  believes 
he  has  discovered  the  glands  which  produce  it.  Did  these 
really  exist,  they  would  augment  in  size_,  instead  of  decreas- 
ing, as  age  advanced,  and  their  functions  becoming  more 
and  more  established,  they  would  attain  to  a  very  large  size 
in  old  persons,  and  those  most  subject  to  tartar.  Now,  there 
is  nothing  to  lead  one  to  suppose  their  existence  in  these  in- 
dividuals. Therefore,  to  suppose  that  organs  that  have  no 
functions  may  be  very  perceptible,  which,  when  they  have 
them,  cannot  be  discovered^  is  contrary  to  sound  philosophy  ; 
were  we  to  do  so  in  this  case,  the  dental  glands  of  the  author 
would  be  entirely  different  from  all  others,  which  are  the 
more  decided  the  more  they  are  in  action.  Inadmissible, 
then  as  this  supposition  is,  I  do  not  believe  in  the  existence 
of  these  glands,  which  I  have  patiently  searched  for,  but 
in  vain," 

Our  own  views  in  relation  to  the  supposed  existence  of 
the  dental  glands  of  M.  Serres,  are  so  fully  expressed  in 
the  foregoing  remarks,  that  we  do  not  deem  it  necessary  to 
say  more  on  the  subject,  except  to  add  what  has  been  sug- 
gested by  others,  that  he  has  evidently  mistaken  the  folli- 
cles of  the  mucous  membrane  of  the  gums  for  glands. 

But  M.  Delabarre  is  not  more  fortunate  in  the  theory 
which  he  advances  of  the  origin  of  salivary  calculus,  than 
Serres.  He  believes  it  to  be  an  exhalation  from  the  mucous 
membrane  of  the  gums.  Alluding  to  what  M.  Dupuy, 
professor  of  the  veterinary  establishment  at  Alfont,  says, 
concerning  the  formation  of  tubercular  matter  of  a  calcare- 
ous nature  in  soft  tissues,  where  he  supposes  there  are  no 
other  fluids  but  mucus,  he  tells  us  that  it  is  '"'in  the  same 
manner  that  the  exhalants  of  the  gums  furnish  tartar,"  and 
that  '^they  give  out  more  or  less  of  it  according  as  the 
gums  are  in  a  healthy  or  inflamed  state."  "When  dis- 
eased," he  says,  ''they  are  covered  with  a  whitish  layer, 
which  is  at  first  soft,"  but  gradually  collecting  upon  the 
teeth,  it  afterwards  becomes  hard  ;  and,  according  to  this 


ORIGIN   AND   DEPOSITION   OF   SALIVARY   CALCULUS.  493 

author,  it  is  only  when  the  gums  are  inflamed  that  it  is  pro- 
duced. 

It  is  in  this  way  that  he  accounts  for  its  accumulation  on 
the  teeth  of  one  side  of  the  mouth,  while  those  of  the  other 
have  none  of  it  on  them,  though  they  are  all  bathed  alike 
in  the  saliva.  The  concretions  of  earthy  salts  in  the  sali- 
vary conduits,  he  accounts  for,  by  supposing  them  to  be  fur- 
nished by  the  exhalants  of  the  mucous  membrane  which 
lines  them_,  and  not  by  the  fluid  they  convey  to  the  mouth. 

He  accounts  for  analogous  formations  in  other  parts,  in 
the  same  way.  The  calculous  incrustations  found  upon  a 
sound,  on  its  removal,  after  having  remained  in  the  blad- 
der for  a  long  time,  and  from  subjects  in  whom  no  previous 
disposition  to  gravel  had  existed,  he  supposes  to  be  the  re- 
sult of  irritation  produced  by  the  instrument,  on  the  mu- 
cous membrane  of  this  viscus.  In  replying  to  this  part  of 
his  argument  in  support  of  his  theory  that  salivary  calculus 
is  furnished  by  the  exhalants  of  the  mucous  membrane  of 
the  mouth,  Mr,  Bell  says,  "The  previous  non-existence  of 
calculus  in  the  bladder  cannot  be  deemed  any  proof  that  the 
elements  of  its  composition  had  not  been  held  in  solution  in 
the  urine,  requiring  only  the  occurrence  of  any  extraneous 
body  in  the  bladder  to  serve  as  a  nucleus  for  its  deposition. 
This  view  of  the  subject  is  amply  confirmed  by  the  fact, 
that  depositions^,  both  of  the  lithic  salts  and  of  the  triple 
phosphate,  the  bases  of  the  usual  varieties  of  urinary  cal- 
culi^ are  constantly  formed  from  the  urine,  after  its  expul- 
sion from  the  bladder." 

It  is  unfortunate  for  M.  Dclabarre,  that  he  drew  this 
analogy,  for  Mr.  Bell  has  shown  it  to  be  conclusive  against 
the  theory  which  he  intended  to  establish  by  it.  He  says, 
"that  salivary  calculus,  or  tartar  of  the  mouth,  is  deposited 
in  a  similar  manner  from  the  saliva,  is,  I  think,  directly 
proved,  or  at  least  supported  by  the  highest  degree  of  prob- 
ability by  every  circumstance  connected  with  its  forma- 
tion." The  factj  too,  that  it  is  always  found  in  largest 
quantity  on  the  teeth   opposite  the  mouths  of  the  salivary 


494         ORIGIN  AND   DEPOSITION   OF  SALIVARY   CALCULUS. 

ducts,  is  a  strong  argument  of  itself,  in  favor  of  the  theory 
that  it  is  a  salivary  formation  ;  but,  still  more  conclusive, 
is  the  fact  of  its  formation  within  the  very  channels  them- 
selves of  these  conduits. 

The  theory  of  M.  Delabarre  is  insufficient  for  the  expla- 
nation of  its  deposition  here,,  for,  it  is  not  presumable,  that 
inflammation  v/ould  seize  upon  a  single  point  of  the  mucous 
membrane  of  one  of  these  passages^  without  afiecting  it  to 
a  considerable  extent.  The  most  probable  cause  of  its  for- 
mation here,  therefore,  appears  to  us,  to  be  the  accidental 
precipitation  of  a  particle  of  it  from  the  saliva  on  its  pass- 
age to  the  mouth,  which,  becoming  entangled  in  the  mu- 
cus, is  detained^  and  afterwards  serves  as  a  nucleus  for  its 
deposition. 

Of  the  existence  of  the  elements  of  its  composition  in  the 
saliva  there  can  be  no  question.  Chemical  analyses  of  this 
fluid,  direct  from  the  glands,  place  all  doubt  upon  the  sub- 
ject at  rest.  Turner,  in  enumerating  its  chemical  con- 
stituents, mentions  as  one,  bone  earth,*  and,  Siedemann, 
Gmelinf  and  Scherer,|  have  detected  phosphate  of  lime,  as 
has  also  Enderlin§  and  other  chemists  who  have  analyzed 
this  fluid.  Thus  it  is  seen  that  the  chief  earthy  constitu- 
ents which  enter  into  the  formation  of  this  substance  are 
contained  in  the  saliva.  It  may  also  exist  in  solution  in 
the  mucous  fluid  of  the  mouth. 

The  circumstance  that  its  deposition  on  the  teeth  is  al- 
ways accompanied  by  inflammation  of  the  gums,  M.  Dela- 
barre seems  to  rely  upon  as  conclusive  in  favor  of  the  cor- 
rectness of  his  views  of  the  manner  of  its  formation.  But 
here  again,  he  is  equally  unfortunate.  The  inflammation 
of  which  he  speaks,  is  the  efiect,  and  not  the  cause,  as  he 
supposes,  of  its  deposition.  The  soft  white  layer  of  tartar, 
of  which  he  makes  mention,  as  observable  on  the  gums, 
when  diseased,  is  nothing  more  than  thick,  hardened  mucus. 

*  Turner's  Chemistry,  p.  756. 

t  Miiller's  Physiology,  vol.  1,  p.  461. 

I  French  Lancet.     April,  1845. 

§  Liebig,  Annalen,  1844,  pp.  3  and  4. 


ORIGIN   AND   DEPOSITION   OF    SALIVARY    CALCULUS.         495 

We  have  repeatedly  examined  it,  and  are  well  assured  of 
the  correctness  of  the  assertion. 

The  deposition  of  tartar  on  the  teeth  of  one  side  of  the 
mouthj  without  a  similar  deposit  on  the  corresponding  teeth 
of  the  opposite  side,  does  not  furnish  the  least  shadow  of 
evidence  in  support  of  the  doctrine  that  it  is  an  exhalation 
from  the  sanguineous  capillaries  of  the  mucous  membrane 
of  the  gums.  The  mastication  of  food,  with  most  persons, 
is  principally  performed  by  the  teeth,  on  one  side  of  the 
mouth,  and,  that  this  function  prevents,  in  a  considerable 
degree,,  the  accumulation  of  tartar  on  the  organs  immedi- 
ately concerned,  is  a  fact  with  which  every  dentist  must  be 
familiar.  Hence,  its  frequent  collection  on  the  teeth  of  one 
side,  and  not  on  those  of  the  other.  And,  that  it  is  ascri- 
bable  to  this  circumstance,  is  susceptible  of  positive  proof. 
If,  on  the  removal  of  the  tartar  from  the  teeth  of  a  person, 
in  whose  mouth  it  has  only  collected  on  those  of  one  side, 
mastication  be  afterwards  altogether  performed  on  these,  it 
will  not  re-accumulate  on  them,  and  if  the  requisite  atten- 
tion to  the  cleanliness  of  the  teeth  on  the  other  side  be  not 
properly  observed,  it  will  soon  collect  there,  although  these 
teeth  had  before  remained  free  from  it. 

Again,  it  often  happens  that  disease  of  a  severe  character, 
is  excited  in  the  gums,  by  the  use  of  mercurial  medicines 
and  other  causes,  and  yet,  but  a  small  quantity  of  tartar 
collects  on  the  teeth ;  but,  that  any  condition  of  the  general 
system,  or  of  the  mouth,  tending  to  increase  the  viscosity  of 
the  fluids  of  this  cavity,  promotes  its  formation,  is  undeni- 
able. There  are,  however,  some  temperaments  much  more 
favorable  to  its  production  than  others^  and,  it  is  a  fact 
equally  well  established,  that  the  mucous  membrane  of  those 
in  whose  mouths  it  accumulates  in  largest  quantity  are 
the  most  irritable,  and  their  buccal  fluids  most  viscid. 
Again,  if  it  were  deposited  by  the  mucous  fluids  of  the 
mouth,  it  would  collect  in  largest  quantities  on  those  teeth 
which  are  less  abundantly  bathed  in  the  saliva,  as  for  ex- 
ample, the  anterior  surfaces  of  the  upper  incisors  and  cus- 


496        ORIGIN   AXD   DEPOSITION   OF    SALIVARY    CALCULUS. 

pids,  while  tliose  opposite  to  the  mouths  of  the  ducts, 
which  discharge  this  fluid  into  the  mouth,  would  be  less 
liable  to  deposits  of  tartar  than  any  of  the  other  teeth. 

From  all  the  light,  therefore,  that  has  been  thrown  upon 
this  subject,  the  conclusion  that  this  earthy  matter  is 
chiefly  a  salivary  deposit,  appears  to  us  irresistible,  and  the 
following  seems  to  be  the  manner  of  its  formation : 

It  is  precipitated  from  the  saliva,  as  this  fluid  enters  the 
mouth,  on  the  surfaces  of  the  teeth,  opposite  the  openings 
into  the  ducts,  from  which  it  is  poured.  To  these,  its  par- 
ticles become  agglutinated  by* the  mucus  always  found,  in 
greater  or  less  quantity,  upon  them.  Particle  after  particle 
is  afterwards  deposited,  until  it  sometimes  accumulates  in 
such  quantities  that  nearly  all  the  teeth  are  almost  entirely 
encrusted  in  it.  It  is  always,  however,  found  in  greatest 
abundance  on  the  outer  surfaces  of  the  superior  molars,  and 
the  inner  surfaces  of  the  inferior  incisors,  and  it  is  opposite 
to  these  that  the  mouths  of  the  salivary  ducts  open. 

EFFECTS  OP   SALIVARY  CALCULUS  UPUN  THE   TEETH,  GUMS  AND 
ALVEOLAR  PROCESSES. 

The  effects  arising  from  the  presence  of  this  substance 
on  the  teeth  are  always  pernicious,  though  sometimes  more 
so  than  others.  An  altered  condition  of  the  fluids  of  the 
mouth,  diseased  gums,  and  not  unfrequently  the  gradual 
destruction  of  the  alveolar  processes,  and  the  loosening  and 
loss  of  the  teeth,  are  among  the  consequences  that  result 
from  it.  But  beside  those,  other  effects  are  sometimes  pro- 
duced; among  which  may  be  enumerated:  tumors  and 
spongy  excrescences  of  the  gums,  of  various  kinds ;  necrosis 
and  exfoliation  of  the  alveolar  processes,  and  jiortions  of  the 
maxillary  bones,  hemorrhages  of  the  gums,  anorexia  and 
derangement  of  the  whole  digestive  apparatus  ;  foul  breath, 
catarrh,  cough,  diarrhea,  diseases  of  various  kinds  in  the 
maxillary  antra  and  nose,  pain  in  the  ear,  head-ache,  mel- 
ancholy, hypochondriasis^  &c.     The  character  of  the  effects, 


I 


MANNER    OF    REMOVING    SALIVARY  CALCULUS.  49T 

however,  both  local  and  constitutional,  depends  upon  the 
quantity  and  consistence  of  the  tartar,  and  the  tempera- 
ment of  the  individual  as  well  as  the  state  of  the  general 
health ;  and  the  two  former  of  these  are  determined  by  the 
two  latter,  and  the  attention  paid  to  the  cleanliness  of  the 
teeth.  If  this  last  be  properly  attended  to,  salivary  calcu- 
lus, no  matter  how  great  the  constitutional  tendency  to  its 
formation  may  be,  will  not  collect  in  large  quantity  upon 
the  teeth.  The  importance,  therefore,  of  its  constant  ob- 
servance,, cannot  be  too  strongly  impressed  upon  the  mind, 
and  especially  upon  those  in  whom  there  exists  a  great  ten- 
dency to  its  deposition. 

The  teeth  and  their  contiguous  parts  suffer  more  from, 
accumulations  of  this   substance,  than   almost   any  other 
cause.     Caries  is  not  much  more  destructive  to  them.  ,^-rr-— ^ 

When  permitted  to  accumulate  for  any  great  length  of  yjty*^ 
time,  the  gums  become  so  morbidly  sensitive,  that  a  tooth-  J^ — • — 
brush  cannot  be  used  without  producing  pain :  consequently^ 
the  cleanliness  of  the  mouth  is  not  attempted,  and  thus,  no  rj — 77 
means  being  taken  to  prevent  its  formation,  it  accumulates  ^^''^'^_. 
with  increased  rapidity,  until  the  teeth,  one  after  another,  a  ^^  eA> 
and  in  quick  succession,  fall  victims  to  its  desolating 
ravages. 

It  sometimes  not  only  undermines  the  soundest  constitu-   /j      "^ 
tions,  by  occasioning  discharges  of  fetid  matter  from  the  L-<M-*nj( 
gums,  and   corrupting  the  juices  of  the  mouth,  but  it  also 
renders  the  breath  exceedingly  unpleasant  and   offensive.    IQ    ^ 

So  nauseating  and   disagreeable  is   the  odor  which  some    ~^ "J 

descriptions  of  tartar  exhale,  that  the  atmosphere  of  a  whole   t.'^'***' 
room  is  contaminated  by  it  in  a  few  minutes,  .  '  C'i*<^ 


MANNER  OP   REMOVING   SALIVARY   CALCULUS. 

This  is  an  operation  of  great  importance  to  the  health  of 
the  gums,  alveolar  processes  and  teeth.  But  from  a  miscon- 
ception of  its  nature,  rather  than  from  fear  of  pain,  many 
are  much  opposed  to  it :  and  notwithstanding  the  uuiver- 


1 


498  MANNER    OF   REMOVING   SALIVARY   CALCULUS. 

versal  admiration  in  wliicli  clean  and  white  teeth  are  held, 
suffer  the  heauty  of  these  organs  to  be  destroyed,  rather  than 
submit  to  its  performance.  There  are  some,  indeed,  who 
though  scrupulously  particular  in  everything  that  regards 
dress,  seem,  nevertheless,  to  consider  the  cleanliness  of 
their  mouths  as  unworthy  of  notice. 

For  the  removal  of  tartar  from  the  teeth,  a  variety  of  in- 
struments are  necessary,  which  should  be  so  constructed, 
that  they  may  be  easily  applied  to  every  part  of  every  tooth. 
The  instruments  put  up  in  small  boxes  and  sold  in  the 
shops,  are  illy  suited  for  the  purpose.  Those  used  by  den- 
tal practitioners  are  so  very  similar  in  their  shape,  and  so 
well  known,  that  we  do  not  deem  it  necessary  to  point  out 
the  minute  differences  of  construction,  or  even  to  give  a 
general  description  of  the  instruments  themselves. 

Every  dentist  should  have  a  sufficient  number  and  variety 
to  enable  him  to  perform  the  operation  in  the  most  perfect 
manner,  and  with  the  least  possible  inconvenience  to  the 
patient. 

If  any  particles  of  tartar  be  suffered  to  remain,  they  will 
irritate  the  gums,  and  serve  as  nuclei  for  immediate  sub- 
sequent re-accumulations. 

The  adhesion  of  tartar  to  the  teeth  is  sometimes  so  great, 
that  considerable  force  is  required  for  its  removal,  even 
when  the  sharpest  and  best  tempered  instruments  are  em- 
ployed. But  ordinarily  it  may  be  removed  with  ease. 
Considerable  tact,  however,  is  necessary  to  perform  the 
oj)eration  in  a  skillful  manner  ;  more  than  most  persons, 
from  its  simplicity,  imagine.  This  skill  can  only  be  ac- 
quired by  practice.  Tartar  may  be  taken  from  the  outer  and 
inner  surfaces  of  the  teeth  without  much  difficulty,  but  the 
removal  of  it  from  between  them,  is  more  troublesome,  and 
and  can  only  be  effected  by  means  of  very  thin,  sharp- 
pointed  instruments. 

Several  sittings  are  sometimes  necessary  for  the  completion 
of  the  operation,  especially  when  the  tartar  has  accumulated 
in  very  large  quantities.     In  cases  of  this  sort,  it  should  be 


MANNER    OF    REMOVING    SALIVARY   CALCULUS.  499 

removed  at  the  first  sitting  from  between  the  edges  of  the 
gums,  and  the  necks  of  the  teeth.  The  mouth  in  the  mean 
time,  during  the  intervals  between  the  several  operations, 
should  be  gargled  several  times  a  day,  with  some  cooling 
and  astringent  wash  ;  but  more  particular  directions  will 
be  given  on  this  subject  in  the  next  chapter. 

During  the  removal  of  tartar  from  the  teeth,  the  gums 
often  bleed  very  freely^  and  when  much  swollen  and  spongy, 
it  may  be  well  to  promote  it  by  holding  tepid  water  in  the 
mouth.  When  the  lower  incisors  are  loose,  as  is  often  the 
case,  the  operation  should  be  proceeded  with  cautiously  to 
prevent  starting  them  from  their  sockets,  and  this  is  the 
more  necessary  when  the  tartar  is  very  hard  and  adheres 
with  great  tenacity. 

Chemical  agents  are  sometimes  employed  for  the  removal 
of  salivary  calculus,  especially  such  of  the  mineral  acids  as 
are  sujiposed  to  have  less  affinity  for  the  lime  of  the  teeth, 
than  the  phosphoric  with  which  it  is  combined  ;  but  it  is 
scarcely  necessary  to  say,  that  any  acid  capable  of  dissolv- 
ing tartar,  will  act  upon  these  organs.  The  use  of  agents  of 
this  sort,  therefore,  should  be  carefully  avoided.  Nearly 
all,  both  of  the  mineral  and  vegetable  acids,  as  has  been 
shown  in  a  preceding  part  of  this  work,  are  prejudicial  to 
the  teeth. 


CHAPTER      SECOND. 
DISEASES    OF    THE    GUMS. 

The  glims  and  alveolar  processes,  from  apparently  tlie 
same  cause,  frequently  assume  various  morbid  conditions. 
An  unhealthy  action  in  one,  is  almost  certain  to  be  followed 
by  disease  in  the  other.  The  most  common  form  of  disease 
to  which  these  parts  are  subject,  is  usually,  though  very 
improperly,  denominated  scurvy,  from  its  supposed  resem- 
blance to  scorbutus,  ''a  genus  of  disease  in  the  class  cachexice, 
and  order  {mpetiginis,  of  Cullen."  To  this  disease,  hoAv- 
ever,  it  bears  no  resemblance.  Instead,  therefore,  of  con- 
tinuing the  use  of  the  term,  we  propose  to  treat  it  under  the 
appellation  of  chronic  inflammation  and  tumefaction  of  the 
gums,  attended  by  recession  of  tlieir  margins  from  the  necks  of 
the  teeth  which  seems  to  express  more  clearly  the  condition 
of  the  parts,  and  the  nature  of  the  disease.  The  gums 
sometimes,  though  less  frequently,  become  the  seat  of  acute 
inflammation.  The  other  affections  to  which  the  gums  are 
liable,  will  be  noticed  under  their  ajipropriate  heads. 

The  diseases  of  the  gums  and  alveolar  processes,  are  di- 
vided by  Mr.  Bell,  into  two  classes:  "those  which  are  the 
result  of  local  irritation,  and  those  which  arise  from  consti- 
tutional causes." 

But  were  it  not  for  local  irritation,  the  constitutional  ten- 
dencies to  disease,  in  these  parts,  would  rarely  manifest 
themselves;  and  on  the  other  hand,  were  it  not  for  constitu- 
tional tendencies,  the  effects  of  local  irritation  would  seldom 
be  of  a  serious  character.  "Thus,"  says  Mr.  B.,  "the  same 
cause  of  irritation,  which,  in  a  healthy  person,  would  occa- 
sion only  a  simple  abscess,  might,  in  a  different  constitu- 


DISEASES   OF   THE   GUMS.  501 

tion,  result  in  ulceration  of  a  decidedly  cancerous  type;  and 
in  others,  in  the  production  of  fungous  tumors,  or  the  for- 
mation of  scrofulous  abscesses." 

Each  constitution  has  its  own  peculiar  tendency,  or  in 
other  words,  is  more  favorable  to  the  development  of  some 
forms  of  disease,  than  others,  and  this  tendency  is  always 
increased  or  diminished,  according  as  the  functional  opera- 
tions of  the  body  generally,  are  healthily  or  unhealthily 
performed.  Thus,  in  an  individual  of  a  mucous  habit,  de- 
rangement of  the  digestive  organs  increases  the  tendency 
superinduced  by  it  to  certain  forms  of  diseased  action  in 
particular  organs,  and  in  none  more  than  the  gums.  A 
local  irritant,  which  would  not  before  have  produced  any- 
thing more  than  slight  inflammation  of  the  margins  of  the 
gums,  would  now  give  rise  to  turgidity  and  sponginess  of 
their  whole  structure.  The  same_,  too,  may  be  said  with 
regard  to  a  person  of  a  scrofulous  or  scorbutic  habit. 

The  susceptibility  of  the  gums  to  the  action  of  morbid 
irritants,  is  always  increased  by  enfeeblement  of  the  vital 
powers  of  the  body.  Hence,  persons  laboring  under  exces- 
sive grief,  melancholy,  or  any  other  affection  of  the  mind, 
or  constitutional  disease,  tending  to  enervate  the  vital 
energies  of  the  system,  are  exceedingly  subject  to  inflam- 
mation, sponginess  and  ulceration  of  the  gums.  But,  not- 
withstanding the  increase  of  susceptibility  which  the  gums 
derive  from  certain  constitutional  causes  and  states  of  the 
general  health,  these  influences,  in  the  majority  of  cases, 
may  all  be  counteracted  by  a  strict  observance  of  the  rules 
of  dental  hygiene;  or,  in  other  words^  by  constant  and 
regular  attention  to  the  cleanliness  of  the  teeth. 

A  local  disease^  situated  in  a  remote  part,  often  has  the 
effect  of  diminishing  tlie  tendency  in  the  gums  to  disease, 
but  when,  from  its  violence  or  long  continuance,  the  general 
health  becomes  implicated,  the  susceptibility  of  these  parts 
is  augmented. 

Although  deriving  the  predisposition  which  they  have  to 
disease,  from  a  specific,    morbid  constitutional   tendency, 


502  ACUTE   INFLAMMATIOX   OF    THE   GUMS. 

tliey,  nevertheless,,  when  diseased,  contribute  in  no  small 
degree  to  derange  the  whole  organism.  An  unhealthy  ac- 
tion here  vitiates  the  fluids  of  the  mouth,  and  renders  them 
unfit  for  the  purposes  for  which  they  are  designed — hence, 
when  these  parts  are  restored  to  health,  whether  from  the 
loss  of  the  teeth,  or  the  treatment  to  which  they  may  have 
been  subjected,  the  condition  of  the  general  health  is  al- 
ways immediately  improved. 

Thus,  while  the  susceptibility  of  the  gums  to  morbid  im- 
pressions is  influenced  by  the  state  of  the  general  health,  the 
latter  is  equally  influenced  by  the  condition  of  the  former. 
And,  not  only  is  a  healthy  condition  of  the  gums  essential 
to  the  general  health  but  it  is  also  essential  to  the  health  of 
the  teeth  and  alveolar  processes.  From  the  intimate  rela- 
tionship that  subsists  between  the  former  and  latter,  disease 
cannot  exist  in  one,  without,  in  some  degree  at  least,  afi"ect- 
ing  the  other.  .  Caries  of  the  teeth,  for  example,  often  gives 
rise  to  inflammation  of  the  gums  and  alveolo-dental  perios- 
teum ;  and^  on  the  other  hand,  inflammation  of  these  partS;, 
vitiates  the  fluids  of  the  mouth,  and  causes  them  to  exert  a 
deleterious  action  upon  the  teeth  as  well  as  upon  other  parts 
of  the  body. 

ACUTE   INFLAMMATION   OF   THE  GUMS. 

Acute  inflammation  of  the  gums,  very  frequently  occurs 
in  connection  with  stomatitis,  or  inflammation  of  the  mu- 
cous membrane  generally^  of  the  buccal  cavity,  which  appears 
under  a  great  variety  of  forms  ;  but  in  this  case,  the  inflam- 
matory action  does  not  always  extend  to  the  subjacent  fibro- 
cartilaginous structure,  and  the  local  disease  is  complicated 
with  other  disorders,  the  treatment  of  which  comes  more 
projierly  within  the  province  of  the  medical  than  that  of  the 
dental  practitioner.  Acute  ulitis,  or  active  inflammation  of 
the  gums,  properly  speaking,  is  in  most  cases,  a  purely  local 
disease,  usually  arising  from  the  irritation  of  dentition,  or 
as  a  consequence  of  periodontitis.     It  often  extends  to  the 


CHRONIC  INFLAMMATION   &C.,    OF  THE   GUMS.  503 

submaxillary  glands  and  muscles  of  the  face^   attended  by 
swelling  and  otlier  morbid  phenomena. 

But  as  this  form  of  inflammation  of  the  gums  is  treated 
of  in  connection  with  other  subjects,  it  will  not  be  necessary 
to  repeat  what  we  have  said  elsewhere  concerning  it. 

CHRONIC   INFLAMMATION  AND   TUMEFACTION   OF   THE  GUMS  AT- 
TENDED BY  RECESSION  OF  THEIR  MARGINS  FROM  THE  TEETH. 

The  affection  on  which  we  are  now  about  to  treat  has  been 
variously  designated.  Jourdain  and  other  French  writers 
term  it,  in  its  more  advanced  stages, '  ^conjoined  suppuration, ' ' 
because  it  is  then  complicated  with  a  discharge  of  purulent 
matter  from  between  the  edges  of  the  gums  and  the  necks  of 
the  teeth,  and  a  gradual  destruction  of  the  alveolar  process- 
es. Dr.  Koecker  calls  it  the  ^^devastating process/'  because 
it  is  attended  by  wasting  of  the  gums  and  alveoli,  but  it  is 
more  frequently  treated  of  under  the  appellation  of  "scurvy' ' 
than  any  other  name. 

Chronic  inflammation  of  the  gums  may  exist  for  years 
without  being  attended  by  suppuration,  or  recession  of  their 
margins  from  the  necks  of  the  teeth,  but,  sooner  or  later, 
according  to  the  amount  of  local  irritation  and  the  state  of 
the  constitutional  health  and  habit  of  body,  these  phenome- 
na are  developed.  With  the  occurrence  of  inflammation  the 
margins  of  the  gums  gradually  lose  their  festooned  apf>ear- 
ance,  become  thick,  spongy  and  rounded,  and  ultimately, 
on  being  pressed_,  purulent  matter  is  discharged  from  be- 
tween them  and  the  necks  of  the  teeth.  Their  sensibility  is 
increased,  and  they  l)leed  from  the  most  trifling  injury. 

The  diseased  action  usually  develops  itself,  first_,  in  the 
gums  around  the  lower  front  teeth  and  the  upper  molars, 
opposite  the  mouths  of  the  salivary  ducts,  and  in  the  imme- 
diate vicinity  of  aching,  decayed,  dead,  loose,  or  irregularly 
arranged  teeth,  or  in  the  neighborhood  of  roots  of  teeth,  and 
from  thence  it  extends  to  the  other  teeth.     The  rapidity  of 


504 


CHRONIC   INFLAMJMATION   &C.,    OF   THE  GUMS. 


its  progress  depends  on  the  age,  state  of  the  general  healthy 
temperament  and  habit  of  body  of  the  individual,  and  the 
character  of  the  local  irritants  which  have  given  rise  to  it. 
It  is  always  more  rapid  in  persons  addicted  to  the  free  use  of 
spirituous  liquors,  and  in  individuals  in  whom  their  exists  a 
scorbutic  tendency,  or  who  have  suffered  from  a  mercurial 
diathesis  of  the  general  system,  or  from  venereal  disease. 

The  inflammation  may  be  confined  to  the  gums  of  two  or 
three  teeth,  or  it  may  extend  to  the  gums  of  all  the  teeth, 
in  one  or  both  jaws. 

The  gums,  as  the  disease 
advances,  begin  to  recede 
from  the  necks  of  the  teeth, 
the  alveoli  to  waste,  and  the 
teeth,  as  they  lose  their 
support,  loosen  and  ulti- 
mately drop  out.  In  Fig. 
146  is  represented  a  case  in 
which  nearly  one-half  of  the  roots  of  the  lower  incisors 
have  become  exposed  from  this  devastating  process. 

But  the  loss  of  the  teeth,  though  it  puts  a  stop  to  the 
local  disease,  is  not  the  only  bad  effect  that  results  from  it. 
Constitutional  symptoms  often  supervene  ;  more  vital  organs 
become  implicated,  and  the  health  of  the  general  system  is 
sometimes  very  seriously  impaired.  Hence,  the  improve- 
ment often  observed  in  the  general  health,  after  the  loss  of 
the  teeth,  of  persons  whose  mouths  have  for  a  long  time 
been  affected  with  this  disease.  No  condition  of  the  mouth 
has  a  greater  tendency  to  deteriorate  its  secretions,  and  im- 
pair the  function  of  mastication  and  digestion  than  the  one 
now  under  consideration. 

In  forming  an  opinion  of  the  injury  likely  to  result  from 
the  disease,  the  dentist  should  be  governed  not  only  by  the 
health  and  age  of  the  patient,  and  the  local  causes  con- 
cerned in  its  production,  but  he  should  also  endeavor  to 
ascertain   whether    it   is   connected   with   a   constitutional 


CHRONIC   INFLAMMATION^    &C.,    OF   THE   GUMS.  505 

tendency,  or  is  purely  a  local  affection.  Some  have  been 
led  to  believe,  tliat  the  wasting  of  the  gums  and  alveolar 
processes  may  sometimes  take  place  without  being  connected 
with  any  special  local,  or  constitutional  cause  ;  that  it  is 
identical  with  that  process  by  which  the  teeth  of  aged  per- 
sons are  removed,  and  that  when  it  occurs  in  persons  not 
past  the  meridian  of  life,  it  is  symptomatic  of  a  sort  of  pre- 
mature old  age. 

Mr.  Bell,  on  this  subject,  remarks  :  "In  forming  a  judg- 
ment upon  a  case  of  this  description,  however,  and  even  on 
those  in  which  the  loss  of  substance  is  associated  with  more 
or  less  of  diseased  action,  it  is  necessary  to  recollect  that  the 
teeth  are  generally  removed  in  old  age  by  this  identical 
mode,  namely,  the  destruction  of  their  support,  by  the  ab- 
sorption of  the  gums  and  alveolar  processes  ;  and  as  this 
stej)  towards  general  decay  commences  at  very  different 
periods  in  different  constitutions,  it  may,  doubtless,  in  many 
cases^  even  in  persons  not  past  the  middle  period  of  life,  be 
considered  as  an  indication  of  a  sort  of  premature  old  age, 
or  an  anticipation,  at  least,  of  senile  decay,  as  far  as  regards 
these  parts  of  the  body." 

The  loss  of  the  teeth,  from  the  wasting  of  the  gums  and 
alveolar  processes,  although  occurring  frequently  in  ad- 
vanced life,  is  not  a  necessary  consequence  of  senility,  for 
we  occasionally  see  persons  of  seventy,  and  even  eighty 
years  of  age,  whose  teeth  are  as  firmly  fixed  in  their  sockets 
and  their  gums  as  little  impaired,  as  in  individuals  at 
twenty.  We  do  not  recollect  ever  to  have  seen  a  case  of  this 
sort  in  which  there  was  not  evidently  some  diseased  action 
in  the  gums.  But  it  is  of  little  importance  whether  it  be 
the  result  of  old  age,  a  constitutional  tendency,  functional 
derangement  of  some  other  part^  or  local  irritation,  since 
the  consequences  resulting  from  such  loss  are  always  the 
same. 

The  gums  after  having  been  once  the  seat  of  chronic  in- 
flammation, are  ever  after  more  susceptible  to  the  action  of 
morbid  irritants. 
33 


506  CAUSES   OF   INFLAMMATION   OF   THE  GUMS. 


CAUSES. 

The  immediate  or  exciting  cause  of  inflammation  of  the 
gums,  is  local  irritation,  produced  by  salivary  calculus, 
carious,  dead,  loose  or  aching  teeth,  or  roots  of  teeth,  or  by 
teeth  which  occupy  a  wrong  position,  or  that  are  crowded  in 
their  arrangement.  It  may  also  be  produced  by  very  hard 
teeth,  which,  in  consequence  of  their  density,  possess  only 
a  very  low  degree  of  vitality.  Cases  of  recession  of  the 
gums^  in  which  only  a  slight  inflammatory  action  exists,  are 
frequently  met  with  in  individuals  having  teeth  of  this  des- 
cription. The  cause  of  this  can  only  be  explained,  by  sup- 
posing a  want  of  congeniality  between  the  organs  and  the 
more  sensitive  and  highly  vitalized  parts  with  which  they 
are  in  immediate  contact.  The  same  thing  is  observed  when 
the  vitality  of  the  teeth  is  weakened  by  age,  which  Mr.  Bell 
regards  as  an  indication  of  senile  decay. 

The  secretions  of  the  mouthy  too,  especially  the  mucus, 
are  often  rendered,  by  certain  conditions  of  the  general  sys- 
tem, so  acrid  as  to  become  a  source  of  irritation  to  the  gums. 

Dr.  Koecker,  who  has  had  the  most  ample  oi^portunities 
of  observing  this  affection  in  all  its  various  forms,  says,  he 
has  never  seen  a  case  of  it  in  which  tartar  was  not  present. 
That  this  is  so  in  a  large  majority  of  the  cases,  there  is  no 
question,  but  that  it  is  in  all,  is  certainly  a  mistake.  The 
author  has  met  with  many,  in  which  not  the  smallest  de- 
posit could  be  detected. 

The  disease  attacks  persons  of  all  ages,  ranks  and  condi- 
tions, and  in  every  country,  climate  and  nation.  "I  have 
observed,"  says  Dr.  Koecker,  ''the  inhabitants  of  the  most 
opposite  countries,  the  Kussians,  the  French,  the  Italians, 
the  Spaniards,  the  Portuguese,  the  English,  the  African,  the 
East  and  West  Indians,  and  those  of  the  United  States,  to 
be  all  more  or  less  liable  to  it. ' ' 

It  is,  however,  more  frequently  met  with  in  tlie  lower 
than  in  the  higher  classes  of  society.     Persons  who  pay  no 


CAUSES   OF   INFLAMMATION   OF   THE   GUMS.  50 Y 

attention  to  the  cleanliness  and  liealtli  of  their  teeth  are 
particularly  subject  to  it.  With  sailors,  and  those  who  live 
principally  on  salt  provisions,  it  is  very  common.  "Per- 
sons of  robust  constitutions,"  says  the  author  just  quoted^ 
"are  much  more  liable  to  this  affection  of  the  gums_,  than 
those  of  delicate  habits ;  and  it  shows  itself  in  its  worst 
forms,  oftener  after  the  age  of  thirty,  than  at  any  earlier 
period." 

To  the  causes  of  irritation,- which  have  already  been 
enumerated,  may  be  added,  accumulations  of  extraneous 
matter  on  the  teeth,  and  along  the  edges  of  the  gums,  ex- 
odontosis,  artificial  teeth  badly  inserted,  or  of  improper 
material,  and  dental  operations  badly  performed.  The  use 
of  improper  tooth-brushes  and  powders,  especially  charcoal, 
may  be  reckoned  among  its  exciting  causes.  The  irrita- 
bility of  the  gums  is  sometimes  increased  by  the  use  of 
acids  ;  at  other  times  it  is  diminished. 

Every  condition  of  the  general  system  tending  to  increase 
the  susceptibility  of  the  gums  to  the  action  of  local  irri- 
tants, favors  the  production  of  the  disease;  and  every  thing 
that  tends  to  induce  such  conditions,  may  be  regarded  as  its 
predisposing  cause  ;  such  as  bilious  and  inflammatory  fevers, 
the  excessive  use  of  mercurial  medicines,  venereal  poison, 
intemperance  and  debauchery.  Any  deterioration  of  the 
fluids  of  the  body  is  peculiarly  conducive  to  it.  Persons  of 
cachectic  habits  are  far  more  subject  to  it,  and  generally  in 
its  worst  forms,  than  individuals  in  the  enjoyment  of  good 
health. 

Strumous  individuals  sometimes  have  an  affection  of  the 
gums,  which  differs  from  the  one  just  described  in  many  re- 
spects. The  gums,  instead  of  being  purple  and  swollen, 
are  paler  and  harder  than  ordinary,  and,  on  being  pressed, 
discharge  muco-purulent  matter,  of  a  dingy  white  color. 
They  often  remain  in  this  condition  for  years,  Avithout  ap- 
pearing to  undergo  any  structural  alteration,  or  to  affect  the 
alveolar  processes. 

The  last  variety  of  disease  of  the  gums,   is  principally 


508  TREATMENT   OF   INFLAMMATION    OF   THE   GUMS. 

confined  to  persons  who  have  very  white  teeth ;  it  is  much 
less  likely  to  attack  males  than  females  ;  and  has  uevcr_,  so 
far  as  we  have  been  able  to  ascertain,  been  mentioned  by 
any  dental  writer.  Mr.  Fox  speaks  of  ulceration  of  the 
gums  of  scrofulous  children;  but  that  is  of  frequent  occur- 
rence, and  is  characterized  by  the  usual  phenomena  of  in- 
flammation. This  rarely  occurs  before  the  age  of  eighteen 
or  twenty;  and  it  seems  to  be  the  result  of  impaired  nutri- 
tion. The  gums  exhibit  no  signs  of  inflammatory  action ; 
on  the  contrary,  they  are  paler,  less  sensitive,  and  possessed 
of  less  warmth  than  usual.  It  is  never  attended  with 
tumefaction  nor  by  absorption,  except  in  its  advanced  stages; 
whereas_,  the  affection  of  which  Mr.  Fox  speaks  is  always 
accompanied  by  both. 

TREATMENT. 

In  the  treatment  of  inflamed,  spongy  and  ulcerated  gums, 
the  first  thing  claiming  attention,  is  the  removal  of  the  ex- 
citing causes.  If  there  are  dead  or  loose  teeth  in  the  mouth, 
or  teeth  which  from  their  position,  act  as  mechanical  irri- 
tants, they  should  be  extracted  at  once.  The  remaining 
teeth  should  at  the  same  time  be  freed  from  all  depositions 
of  tartar  and  other  irritating  foreign  matter. 

Dr.  Koecker  goes  so  far  as  to  recommend  the  extraction 
of  any  molar  tooth,  particularly  of  the  upper  jaw,  which 
has  lost  its  antagonist,  believing  that  a  tooth  under  such 
circumstances  is  a  source  of  irritation  to  the  alveolo-dental 
periosteum  and  gums. 

'■'In  this  manner/'  says  Dr.  K.,  ^'the  loss  of  one  molar 
tooth,  produces  the  destruction  of  its  remaining  antagonist. 
This  is  effected,  however,  after  a  struggle  of  nature,  of  very 
long  duration,  which  always  involve,  in  some  degree,  all 
the  other  teeth  in  a  like  diseased  condition;  it  is  necessary, 
therefore,   to   prevent   this   morbid  condition,  particularly 


TREATMENT   OF   INFLAMMATION   OF  THE   GUMS.  509 

pernicious  in  this  disease,  by  the  extraction  of  the  tooth,  or 
any  molar  so  situated." 

Although  a  molar  tooth,  after  having  lost  its  antagonist, 
is  sometimes  a  source  of  irritation,  it  may  often  remain 
with  impunity.  Its  removal  is  necessary  only  when  it  acts 
as  an  irritant  to  the  gums,  and  it  may  in  a  majority  of  cases 
be  prevented  from  doing  this  by  keeping  it  constantly 
clean. 

It  is  essential  in  the  treatment  of  the  disease  under  con- 
sideration that  a  decided  impression  be  made  upon  it  at 
once ;  consequently  no  time  should  be  lost  in  the  removal  of 
local  exciting  causes.  "The  advantage  derived  from  this 
operation,"  (extraction  of  dead,  loose  or  irritating  teeth,) 
says  Dr.  Koecker,  "would  be  either  partly  or  wholly  lost, 
were  it  performed  at  different  periods."  This  observation 
has  been  verified  by  the  author  more  than  once.  When  he 
has  been  prevented  by  the  timidity  of  his  patient  from  ex- 
tracting all  the  offending  teeth,  at  the  first  sitting,  he  has 
always  found  the  cure  much  retarded,  and  in  some  instances, 
almost  entirely  defeated. 

The  extraction  of  such  teeth  as  it  may  be  necessary  to  re- 
move having  been  effected.  Dr.  Koecker  thinks  it  better  to 
wait  ten  or  fifteen  days  before  the  tartar  is  removed.  The 
author  has  never  been  able  to  discover  any  advantage  from 
such  delay ;  on  the  contrary,  he  regards  it  as  important 
that  as  much  as  possible  should  be  taken  from  the  teeth  at 
the  same  time.  Several  sittings,  however,  are  often  re- 
quired for  its  complete  removal. 

The  bleeding  from  the  gums  and  sockets,  occasioned  by 
these  several  operations,  should  be  promoted  by  frequently 
washing  the  mouth  with  warm  water;  and  when  the  gums 
are  much  swollen,  advantage  will  be  derived  from  scarify- 
ing them  freely  every  three  or  four  days  with  a  sharp  lan- 
cet. This  last  operation  is  highly  recommended  by  Messrs. 
Hunter,  Fox  and  Bell,  and  indeed  its  good  efiects  are  so  ap- 
parent, that  it  should  never  be  neglected. 

The  cure  may  be  hastened  by  washing  the  mouth  several 


510  TREATMENT   OF   INFLAMMATION   OF   THE   GUMS. 

times  a  day  with  some  tonic  and  astringent  lotion.     The 
author  has  found  the  following  to  be  very  serviceable: 

R 


Pul.  nut  gall, 

3  ij. 

/ 

Orris  root, 

5  i. 

ss 

Cort.  cinchon^e, 

3  ij. 

/ 

Infus.  ros£e. 

i  iv. 

Misce. 

L. 

Mr.  Fox  says,  great  benefit  is  derived  from  the  use  of  sea 
water,  and  he  recommends  it  whenever  it  can  be  procured ; 
adding,  that  if  the  gums  be  tender,  it  should  be  used 
warm.  We  are  unable  to  speak  of  the  merits  of  this 
remedy  from  experience^  never  having  tried  it.  We  have, 
in  cases  where  there  was  much  soreness  and  ulceration  of 
the  gums,  prescribed  the  following: 

R     Sub  boras  soda,  3  ij. 

Decoct,  sage,  §  vj. 

Honey,  i  i.     Misce. 

As  a  wash  for  the  mouth,  Dr.  Fitch  recommends  a  de- 
coction of  the  inner  bark  of  green  white  oak,  which  we  have 
found  beneficial.  The  following  are  recommended  by  Dr. 
Koecker,  as  being  very  serviceable: 

"Take  of  clarified  honey^  three  ounces,  and  of  vinegar, 
one  ounce.  This,  diluted  in  the  proportion  of  three  table- 
spoonfuls  to  a  pint  of  warm  sage  tea^  or  water,  may  be  used 
frequently  during  the  day. 

"Take  of  clarified  honey,  and  of  the  tincture  of  bark, 
two  ounces  each.     Mix  and  dilute  as  above. 

"Take  of  honey,  and  of  the  tincture  of  myrrh,  two 
ounces  each.     Mix  and  use  as  above. 

Mr.  Bell  recommends  the  following: 

R     Alumnire,  3  ij. 

Decoct,  cinchonee, 

Infus.  rosae  a  3  ij.     Misce.     Fiat  lotis. 


TREATMENT  OF  INFLAMMATION  OF  THE  GUMS.      511 

But  when  the  last  prescription  is  used,  the  mouth  imme- 
diately after,  should  be  thoroughly  washed  with  water  and 
a  soft  brush,  to  prevent  the  sulphuric  acid  of  the  alum  from 
exercising  a  hurtful  effect  upon  the  teeth. 

The  pleasantest,  and  at  the  same  time  the  most  efficacious, 
lotion  which  the  author  has  ever  employed,  is  the  following  : 


R 


Tannin, 

S   iss. 

Pyrethrum, 

i   i. 

Orris  root. 

S   i. 

Flor.  benzoin. 

§    i- 

Cinnamon, 

I    i. 

Sub-borate  of  soda. 

3    i. 

South  American  soap-tree  bark, 

i    viij 

Sach.  alb. 

ife  i. 

01.  Gaultheria, 

§    ss. 

Ess.  peppermint, 

S   viij 

Alcohol, 

0   iij. 

Aqua  font. 

0   V. 

Coccus  cactus, 

3    iij. 

B   1. 


\ 


Misce — digest  for  six  days  and  filter. 

If,  notwithstanding  the  use  of  the  means  here  recom- 
mended, matter  still  be  discharged  from  around  the  necks 
of  the  teeth,  and  the  gums  continue  spongy,  and  manifest 
no  disposition  to  heal,  their  edges  may  be  touched  with  a 
strong  solution  of  the  nitrate  of  silver.  This  will  seldom 
fail  to  impart  to  them  a  healthy  action.  It  may  be  used  in 
the  proportion  of  from  three  to  twelve  grains  to  one  ounce 
of  water.  The  most  convenient  mode  of  applying  it,  is 
with  a  camel's-hair  pencil.  Its  use  is  recommended  by  Mr. 
Fox,  and  will  often  succeed,  when  other  remedies  fail.  In 
those  cases  where  the  matter  discharged  from  the  edges  of 
the  gums  has  a  nauseating  and  disagreeable  odor,  '^a  weak 
solution/'  says  he,  "is  an  excellent  remedy  for  rendering 
the  mouth  sweet  and  comfortable;"  but  in  using  it  in  this 


1 


512  TREATMENT   OF   INFLAMMATION   OF   THE   GUMS. 

way,  precaution   is  necessary  to  prevent  it  getting  in  the 
fauces,  as,  in  this  case,  it  will  cause  disagreeable  nausea. 

While  the  means  here  directed  for  the  cure  of  the  disease 
are  being  employed,  a  recurrence  of  its  exciting  causes  must 
be  studiously  guarded  against.  Tartar  and  foreign  matter 
of  every  kind,  should  be  prevented  from  accumulating  on 
the  teeth,  by  a  free  and  frequent  use  of  a  suitable  brush 
and  waxed  floss  silk,  which  until  a  healthy  action  be  im- 
parted to  the  gums,  should  be  used  at  least  five  times  a  day ; 
as,  for  example,,  immediately  after  rising  in  the  morning, 
after  each  meal,  and  before  retiring  at  night.  The  appli- 
cation of  the  brush  may  at  first  occasion  some  pain ;  but  its 
use  should,  nevertheless,  be  persisted  in;  for,  Avithout  it,  all 
the  other  remedies  will  be  of  but  little  avail.  The  friction 
produced  by  it,  besides  keeping  the  teeth  clean,  is  of  great 
service  to  the  gums  in  imparting  to  them  a  healthy  action. 

Treatment,  different  from  that  here  described,  is  neces- 
sary for  the  form  of  disease,  which  we  noticed,  as  being 
characterized  by  preternatural  paleness,  and  discharge  of 
muco-purulent  matter,  from  between  the  edges  of  the  gums 
and  the  necks  of  the  teeth.  In  the  first  case  of  this  disease, 
treated  by  the  author,  he  directed  astringent  and  detergent 
lotions  to  be  used ;  but  these  did  not  produce  the  desired 
effect.  Having  been  led  from  his  observations  in  this  case, 
to  believe  that  the  disease  was  connected  with  the  state  of 
the  constitutional  health,  and  was  probably  the  result  of  a 
debilitated  condition  of  the  general  system^  he  recom- 
mended in  the  next  case,  the  use  of  tonics  and  free  exercise 
in  the  open  air.  This  course,  though  attended  with  evident 
improvement  of  the  general  health,  seemed  to  be  productive 
of  no  benefit  to  the  gums.  They  still  appeared  debilitated, 
and  on  being  pressed,  discharged  matter  from  beneath  their 
edges.  He  advised  a  continuance  of  the  tonics  and  exer- 
cise, and  with  a  view  of  exciting  inflammation,  touched  the 
edges  of  the  gums  with  nitrate  of  silver.  This  had  the  de- 
sired effect,  and,  as  he  had  anticipated,  a  new  disease  was 
substituted  for  the  old  one;  for  the  cure  of  wliich,  he  di- 


TREATMENT  OF   INFLAMMATION   OF  THE   GUMS,  5l3 

rected  the  mouth  to  he  washed,  five  or  six  times  a  day, 
with  sage  tea,  slightly  impregnated  with  alum,  and  sweetened 
with  honey,  and  at  night  and  morning  with  salt  water. 

This  treatment  was  perfectly  successful.  In  about  three 
weeks  the  gums  assumed  a  healthy  appearance,  acquired 
their  natural  color,  and  the  discharge  of  muco-purulent  mat- 
ter entirely  ceased.  He  has  since  had  occasion  to  treat  sev- 
eral other  cases,  in  all  of  which  he  adopted  the  same  treat- 
ment, and  with  like  success. 

MORBID  GROWTH  OF  THE  GUMS. 

The  structural  changes  which  take  place  in  the  gums,  as 
a  consequence  of  increased  vascular  action,  are  almost  as  va- 
rious as  are  the  constitutional  tendencies  of  different  indi- 
viduals. Those  characterizing  the  affection  last  noticed, 
consist,  for  the  most  part,  in  increased  thickness  and  reces- 
sion of  their  edges  from  the  necks  of  the  teeth  ;  but  in  the 
one  on  which  we  are  now  about  to  treat,  there  is  morbid 
growth  which  is  sometimes  so  considerable,  that  it  almost 
covers  the  crowns  of  the  t^th,  thus  interfering  very  seriously 
with  the  function  of  mastication.  When  thus  affected,  the 
gums  have  a  dark  purple  color,  thick,  smooth  and  rounded 
margins,  and  discharge  almost  constantly  from  their  inner 
surface,  a  thin,  purulent  matter,  which  exhales  an  exceed- 
ingly offensive  odor.  They  bleed  profusely  from  the  slight- 
est injury,  and  are  so  sensitive  that  the  pressure  even  of  the 
lips  is  sometimes  attended  with  pain.  They  are  also  affect- 
ed with  a  peculiar  itching  sensation,  which,  at  times,  is  a 
source  of  great  annoyance. 

The  accompanying  engraving  will  convey  to  the  reader,  a 
more  correct  idea  of  the  appearance  of  the  gums,  when 
thus  affected  than  any  description  which  can  be  given.  It 
will  be  perceived  from  this,  that  the  morbid  growth  extends 
to  the  gums  of  all  the  teeth,  as  it  usually  does,  when  they 
become  the  seat  of  this  variety  of  diseased  action. 

Among  the  local  and  constitutional  effects  arising  from 


514 


TREATMENT  OF  MORBID  GROWTH  OF  THE  GUMS. 


Fig.  147. 


the  disease  are,  offensive 
treath,  vitiated  saliva, 
destruction  of  the  alveo- 
li, with  loosening  and  ul- 
timately loss  of  the  teeth, 
imi)aired  digestion,  with 
all  its  disagreeable  con- 
comitants, enlargement 
of  the  tonsils  and  bron- 
chitis, together  with  a 
long  train  of  other  mor- 
bid phenomena. 


CAUSES. 

The  exciting  cause  of  this  peculiar  affection  is  local  irri- 
tation, produced  by  salivary  calculus,  dead,  diseased  or  ir- 
regularly arranged  teeth,  but  the  character  of  the  structur- 
al alteration  is  evidently  determined  by  some  cachectic  habit 
of  body  or  constitutional  tendency.  It  often  attacks  the 
gums  of  individuals  whose  teeth  'are  sound  and  well  ar- 
ranged, but  the  author  has  never  met  with  a  case  in  which 
tartar  was  not  present,  though,  in  some  instances,  the  quan- 
tity was  so  small  as  almost  to  lead  one  to  doubt  whether  it 
would  have  had  much  agency  in  the  production  of  the  dis- 
ease. But  the  susceptibility  of  the  gums  to  morbid  impres- 
sions, in  individuals  liable  to  this  affection,  is  usually  so 
great,  that  an  irritant,  which,  under  other  circumstances 
would  scarcely  excite  an  increase  of  vascular  action,  gives 
rise,  in  cases  of  this  sort,  to  the  rapid  development  of  an  ag- 
gravated form  of  disease. 

TREATMENT. 


The  first  thing  to  be  attended  to  in  the  treatment  of  the 
disease,  is  the  removal  of  all  dead  and  such  other  teeth  as 
may,  in  any  way,  irritate  the  gums.     The  morbid  growth 


MERCURIAL  INFLAMMATION   OF  THE   GUMS.  515 

should  be  next  removed,  by  making  a  horizontal  incision 
entirely  through  the  diseased  gums  to  the  crowns  of  the 
teeth.  This  should  be  carried  as  far  back  as  the  morbid 
growth  extends.  After  this,  the  gums  should  be  freely 
scarified  by  passing  a  lancet  betAveen  the  teeth  down  to  the 
alveoli,  in  order  that  the  vessels  may  be  completely  divided, 
and  discharge  their  accumulated  blood.  This  should  be  re- 
peated several  times,  and  at  intervals  of  four  or  five  days. 
Meanwhile  the  mouth  may  be  washed  several  times  a  day 
with  some  astringent  and  detergent  lotion,  and  occasionally 
with  a  weak  solution  of  nitrate  of  silver.  The  tartar  should 
be  removed  as  soon  as  the  gums  have  sufficiently  collapsed 
to  admit  of  the  operation. 

The  progress  of  the  disease  may  be  arrested,  but  a  cure 
cannot  be  afifected  by  mere  local  treatment.  Particular  at- 
tention should  be  j)aid  to  the  regimen  of  the  patient,  and 
such  general  remedies  prescribed  as  the  peculiar  nature  of 
the  case  may  indicate.  Excesses  and  intemperance  of  every 
kind  must  be  avoided.  The  diet  should  consist  principally 
of  vegetables.  If  animal  food  be  used,  it  should  consist  of 
fresh  meats,  such  as  beef,  mutton  and  fowls.  Fruits  and 
acid  beverages,  such  as  infusions  of  malt  and  vinegar,  lime 
juice,  spruce  beer,  &c.,  may  be  used  with  advantage. 

The  teeth  should  be  kept  perfectly  and  constantly  clean. 
Not  a  particle  of  foreign  matter  should  be  permitted  to  re- 
main between  them  or  along  the  edges  of  the  gums.  The 
most  scrupulous  attention  to  this  precaution  is  indispensably 
necessary.  It  constitutes  one  of  the  most  important  reme- 
dial indications. 

MERCURIAL  INFLAMMATION  OP  THE  GUMS. 

The  frequently  repeated  introduction  of  mercury  into  the 
system,  when  taken  in  sufficient  quantity,  gives  rise  to  the 
development  of  peculiar  morbid  phenomena  in  the  gums  and 
other  parts  of  the  mouth.  The  first  indication  of  the  spe- 
cific action  of  this  powerful  medicinal  agent  upon  the  animal 
economy,  consists  in  a  slightly  increased  redness  and  tume- 


516  MERCURIAL   INFLAMMATION   OF   THE   GUMS. 

faction  of  the  free  edges  of  the  gums  around  the  neeks  of 
the  inferior  incisors,  while  the  investing  mucous  membrane 
of  the  adherent  portion,  a  little  lower  down,  often  assumes 
a  white  color,  owing  to  the  oj)acity  of  the  epithelium.  These 
appearances  are  soon  followed  by  increased  secretion  of 
saliva,  a  brassy  or  coppery  taste,  soreness  of  the  teeth  and 
gums,  inflammation  and  swelling  of  the  mucous  membrane 
of  the  roof  the  mouth,  fauces,  cheeks  and  salivary  glands, 
swelling  of  the  tongue^  with  increased  redness  of  its  edges, 
and  a  peculiarly  offensive  odor  of  breath.  In  the  meantime, 
the  edges  of  the  gums  about  the  necks  of  the  teeth  swell  and 
assume  an  increase  of  redness  ;  the  saliva  becomes  viscid  and 
is  secreted  in  such  abundance  as  to  flow  from  the  mouth, 
and  the  movements  of  the  jaws  are  attended  with  pain. 
The  alveolo-dental  periosteum  is  thickened^  and  the  teeth 
raised  from  their  sockets  and  loosened.  A  vesicular  eruption 
sometimes  appears,  followed  by  ulceration  and  sloughing  of 
the  gums,  and  very  frequently  by  necrosis  of  large  portions 
of  the  alveolar  processes  and  jaw-bones.  We  were  shown  a 
few  years  since,  the  entire  alveolar  border  of  both  jaws,  the 
necrosis  and  exfoliation  of  which  had  been  occasioned  by 
severe  mercurial  salivation,  and  we  have  frequently  had 
occasion  to  remove  i)ortions  both  of  the  superior  and  inferior 
maxillary  bones — the  necrosis  having  been  occasioned  by 
the  use  of  this  medicine. 

By  the  prudent  administration  of  mercury,  however,  sali- 
vation may  be  induced,  without  causing  the  deplorable 
effects  just  described.  But  the  specific  action  of  this  agent 
upon  the  constitution  is  always  attended  by  more  or  less 
tumefaction  and  sponginess  of  the  gums,  and  when  once 
brought  under  its  influence,  liowever  perfectly  its  effects  may 
have  subsided,  they  are  ever  after  more  susceptible  to  mor- 
bid impressions. 

TREATMENT. 

It  is  scarcely  necessary  to  say,  that  until  the  use  of  the 
mineral  is  discontinued,  it  will  be  impossible  to  remove  or 


ULCERATION   OF   THE   GUMS   OF   CHILDREN.  517 

even  counteract  its  effects  upon  the  gums,  but  in  mild  cases 
these  usually  soon  disappear  after  the  action  which  it  has 
produced  on  tlie  general  system  has  completely  subsided. 
But  Avhen  they  continue  spongy,  the  bowels  should  be  kept 
open  witli  saline  aperients,  the  patient  restricted  to  a  fluid 
farinaceous  diet,  and  the  mouth  gargled  several  times  a  day 
with  demulcent  decoctions  and  mild  astringent  lotions,  to 
which  it  may  sometimes  bo  advisable  to  add  a  little  lauda- 
num. Washes  made  from  chloride  of  soda  or  lime  may  be 
used  to  correct  the  excessive  fetor  of  the  breath. 

After  the  action  of  the  medicine  upon  the  system  has  sub- 
sided and  the  disease  assumed  a  chronic  form,  the  gums,  as 
directed  by  Mr.  Thos.  Bell,  should  be  freely  scarified  by 
passing  a  lancet  entirely  through  their  substance  between 
the  teeth,  and  this  operation  should  be  repeated  as  often  as 
every  four  or  five  days,  until  they  are  completely  restored. 
The  use  of  astringent  washes  should  at  the  same  time  be 
continued,  and  if  there  are  any  teeth  which,  from  the  less 
of  their  vitality,  or  from  having  become  very  much  loosened 
by  the  partial  destruction  of  their  sockets,  act  as  irritants, 
they  should  be  removed. 

When  the  gums  have  ulcerated,  the  application  of  a  strong 
solution  of  sulphate  of  zinc  or  nitrate  of  silver  with  a  camel's- 
hair  pencil  is  recommended.  Chomel,  an  eminent  French 
physician,  has  employed  with  advantage,  in  cases  of  mercu- 
rial stomatitis_,  vapor  baths. 

ULCERATION  OF  THE  GUMS  OP  CHILDREN,  ATTENDED  WITH  EXFO- 
LIATION OP  THE  ALVEOLAR  PROCESSES. 

The  gums  and  alveolar  processes  of  children  are  occasion- 
ally attacked  by  a  very  peculiar  and  most  singular  form  of 
disease,  and  it  occurs  more  frequently  during  the  shedding 
of  the  temporary  and  the  dentition  of  the  permanent  teeth, 
than  at  any  other  period  of  childhood.  We  have  never 
known  adults  to  be  affected  with  it,  and  to  the  ordinary 
spongy,  inflamed  and  ulcerated  gums,  it  does  not  appear 


518  ULCERATION   OF   THE   GUMS   OF   CHILDREN. 

to  be  at  all  analogous.  It  bears  a  much  closer  resemblance 
to  cancrum  oris,  yet,  in  many  particulars,  it  differs  from  this 
disease. 

Among  the  symptoms  which  characterize  the  affection, 
are  itching,  ulceration  and  separation  of  the  gums  from  the 
necks  of  the  teeth  and  alveolar  processes  ;  there  is,  at  first, 
a  discharge  of  muco-purulent  matter  from  between  the  gums 
and  necks  of  the  teeth,  but  this  ultimately  becomes  ichorous 
and  fetid.  The  teeth  loosen,  and  the  alveoli  lose  their  vi- 
tality and  exfoliate.  Ulcers  are  formed  in  various  parts  of 
the  mouth,  the  gums  and  lii)s  assume  a  deep  red  or  purple 
color.  In  the  exfoliation  of  the  alveolar  processes,  the  tem- 
porary, and  sometimes  the  crowns  of  the  permanent  teeth, 
are  carried  away.  The  skin,  for  the  most  part,  is  dry  ;  the 
pulse  small  and  quick,  the  bowels  generally  constipated, 
though  sometimes  there  is  diarrhea,  and  to  these  symptoms 
may  be  added  lassitude  and  a  disposition  to  sleep. 

These  maybe  regarded  as  the  most  prominent  phenomena 
of  the  disease  in  its  most  aggravated  form.  When  exfolia- 
tion of  the  alveolar  processes  takes  place,  the  symptoms 
usually  abate,  and  sometimes  wholly  disappear.  Delabarre 
sayb,  -'among  the  great  number  of  children  that  are  brought 
to  the  orphan  asylum,  he  has  had  frequent  occasion  to 
notice  singular  complications  of  the  affection,"  which  are 
modified  according  to  the  strength,  "sex,  and  idiosyncrasies 
of  the  different  subjects."  The  gums  and  lips,  in  some, 
he  describes  as  being  of  a  beautiful  red  color  ;  in  others,  the 
lips  are  rosy  and  the  gums  pale,  and  sometimes  very  much 
swollen.  He  also  enumerates  among  tlie  symptoms,  burn- 
ing pain  in  the  mucous  membrane  of  the  cheeks,  ulceration, 
pain  and  swelling  in  the  submaxillary  glands. 

In  the  majority  of  cases,  the  disease  is  confined  to  one 
jaw  and  to  one  side,  though  sometimes  both  are  affected  by 
it.  The  effects  on  the  permanent  teeth,  in  all  the  cases 
which  have  fallen  under  the  notice  of  the  author,  were 
always  injurious,  though  Delabarre  says,  if  children  reach 
the  seventh  or  eighth  year,  they  are  not  injured,  except  that 


CAUSES   OF  ULCERATION   OF  THE  GUMS.  619 

it  causes  them  to  be  badly  arranged,  in  consequence  of  the 
want  of  a  proper  development  of  the  jaw. 

The  author  from  whom  we  have  just  quoted^  enumerates 
among  the  symptoms  of  the  most  aggravated  form  of  the 
disease,  inordinate  appetite,  burning  thirst,  a  small  spot 
on  the  cheek,  or  about  the  lijjs,  resembling  an  anthrax^ 
which  raj)idly  increases  in  size,  turns  black,  sej)arates,  dis- 
charges an  ichorous  fluid,  and  its  edges  "roll  themselves  up 
like  flesh  exposed  to  the  action  of  a  brisk  fire."  The  flesh 
separates  from  the  face  ;  the  bones  become  exposed,  hectic 
fever  ensues,  and  in  the  course  of  fifteen  or  twenty  days, 
death  puts  an  end  to  the  sufierings  of  the  child.  We  are  also 
informed  by  Delabarre,  that  this  affection  is  more  common 
among  females  than  males,  and  that  the  bones  of  the  jaw  are 
so  much  softened  that  they  may  be  easily  cut  with  a  knife. 

CAUSES. 

The  disease  seems  to  be  the  result  of  general  debility  or 
defective  nutrition  and  a  cachectic  habit  of  body.  It  never 
occurs  among  the  wealthy,  but  is  always  confined  to  children 
of  the  poor  and  destitute,  and  so  far  as  the  author's  observa- 
tions extend,  to  those  who  reside  in  cellars  or  small  and 
confined  apartments.  Children  of  scorbutic  habits,  too, 
seem  to  be  the  most  subject  to  it.  Delabarre,  however, 
says  he  has  met  with  it  in  children  who  appear  robust,  and 
in  other  respects  well.  Its  "seat  is  in  the  organs  of  nutri- 
tion, and  in  the  fluids  that  are  conveyed  to  them."  The 
disposition  of  body  which  gives  rise  to  it,  he  mentions 
as  being  sometimes  innate,  and  sometimes  the  result  of  suf- 
fering from  want  of  proper  nourishment.  He  does  not 
think  it  arises  from  a  distinct  disturbance  of  any  organ  sep 
arately  considered. 

From  the  great  debility  of  all  the  organs  of  the  body, 
their  functions  arc  languidly  and  imperfectly  performed. 
Tliat  the  disease  is  determined  by  general  enfeeblement  of 
the  functions  of  the  body,  there  is,  we  think,  little  doubt ; 


520  TREATMENT   OF   ULCERATION   OF   THE   GUMS. 

but  wlietlier  or  not  it  would  develop  itself  independently  of 
any  local  cause,  is  a  question  which  we  do  not  feel  ourself 
able  satisfactorily  to  answer.  It  is  not  at  all  improbable, 
however,  that  local  irritants  are  the  exciting  cause,  and  we 
are  the  more  inclined  to  this  belief  from  the  fact,  that  in  all 
the  cases  which  have  fallen  under  our  observation,  the  teeth 
were  considerably  decayed,  and  had  previously  given  rise  to 
pain,  and  in  some,  they  were  coated  with  tartar.  While, 
therefore,  the  character  of  the  affection  is  determined  by 
some  peculiar  constitutional  tendency  and  general  enfeeble- 
ment  of  the  vital  powers  of  the  body,  it  is  not  unlikely,  that 
local  irritation  is  the  immediate  cause  of  its  development. 

TREATMENT. 

As  the  treatment  of  this  affection  comes  more  immedi- 
ately within  the  province  of  the  medical  than  the  dental 
practitioner,  we  shall  not  dwell  long  upon  the  subject. 

The  local  treatment  should  consist  of  acidulated  and  as- 
tringent gargles,  and  a  solution  of  the  chloride  of  lime  or 
soda.  The  ulcerated  parts  may  be  occasionally  touched 
with  a  strong  solution  of  the  nitrate  of  silver,  and  Delabarre 
says^  he  has  in  some  cases^  derived  great  advantage  from 
touching  them  with  the  actual  cautery.  As  soon  as  the 
alveolar  processes  exfoliate,  they  should  be  removed.  After 
this  takes  place,  a  cure,  with  suitable  constitutional  treat- 
ment, is  generally  speedily  effected.  This  last  may  consist 
of  mild  alteratives,  a  generous  nutritive  diet,  consisting  of 
succulent  vegetables ;  and  in  the  absence  of  fever,  tonics 
and  exercise  in  the  open  air. 

The  author  just  quoted,  with  a  view  to  arouse  the  vital- 
ity, says,  he  has  ^'successfully  employed  the  juice  of  crucif- 
erous 'plants^  the  guinea  in  poiuders,"  but  with  the  last  he 
unites  opium,  in  order  to  diminish  the  action  of  the  digest- 
ive apparatus.  Counter-irritants,  such  as  blisters,  he  em- 
ploys wlien  necessary  to  displace  irritation  of  some  interior 
organ. 


ADHESION  OF  THE  GUMS  TO  THE  CHEEKS.       521 


ADHESION   OF   THE   GUMS   TO   THE   CHEEKS. 

The  gums  and  inner  walls  of  the  cheeks  sometimes  con- 
tract adhesions  which  interfere  serionsly  with  the  functions 
of  the  mouth.  The  affection  may  he  congenital,  hut  in  a 
majority  of  the  cases  it  occurs  subsequently  to  birth.  The 
extent  of  the  adhesion  may  be  small,  or  it  may  occupy  the 
gums  of  the  entire  alveolar  border  of  one  or  both  sides  of 
the  mouth,  and  of  one  or  of  both  jaws.  Desirabode  relates 
the  case  of  a  young  man,  who,  in  consequence  of  a  venereal 
ulcer,  had  his  upper  lip  united  to  the  gums  of  the  four 
incisors  in  such  a  way  as  to  form  a  sort  of  loop  above  the 
teeth,  and  which  by  the  retraction  of  the  lip,  were  caused  to 
jut  out.* 

Adhesion  of  the  gums  to  the  cheeks  or  lips,  results  from 
ulceration  of  the  contiguous  structures_,  whether  caused  by 
constitutional  disease  or  local  lesions.  But  that  it  arises 
more  frequently  as  a  consequence  of  the  immoderate  use  of 
mercury  than  from  any  other  cause,  is  a  universally  ad- 
mitted fact.  The  author  has  met  with  several  cases,  how- 
ever, in  which  the  affection  had  resulted  from  ulceration  of 
the  gums  of  necrosed  temporary  teeth,  and  of  the  corres- 
ponding wall  of  the  cheek,  caused  by  excoriation  of  the  mu- 
cous membrane,  produced  by  the  sharp  points  of  the  pro- 
truding roots.  But  the  extent  of  the  union  in  cases  of  this 
sort,  is  never  very  considerable. 

The  proper  remedial  indication  in  a  case  of  this  kind, 
consists  in  separating  the  parts  which  have  grown  together 
-with  a  sharp  bistoury.  This  done,  reunion  should  be  pre- 
vented by  keeping  a  piece  of  cotton  or  lint  in  the  wound, 
until  the  process  of  cicatrization  is  completed. 

*  Author's  translation  of  Desirabode's  Complete  Elements  of  the  Science  and  Art 
of  the  Dentist,  page  227. 


34 


CHAPTER      FIFTH. 

TUMORS  AND  EXCRESCENCES  OF  THE  GUMS  AND  AL- 
VEOLAR PROCESSES. 

From  the  gums  and  alveolar  processes,  tumors  and  ex- 
crescences of  various  kinds  are  occasionally  developed,  vary- 
ing in  character,  from  a  mere  simple  growth  of  the  gums,  to 
morbid  productions  of  a  fungoid,  cartilaginous,  bony  or 
scirrhous  nature. 

Some  are  smooth,  others  rough,  and  sometimes  covered 
with  eroding  ulcers  ;  some  are  bulbous,  with  a  broad  base ; 
others  are  attached  by  a  mere  peduncle  ;  some  are  soft ; 
others  are  hard:  the  growth  of  some  is  astonishingly  rapid; 
that  of  others  is  so  slow  as  to  be  scarcely  perceptible :  some 
are  almost  entirely  destitute  of  blood  vessels  ;  others  appear 
to  be  almost  wholly  composed  of  sanguiferous  capillaries  : 
some  are  nearly  destitute  of  sensibilit}^  ;  others  are  so  ex- 
quisitely sensitive,  that  the  slightest  touch  produces  great 
pain  ;  and  hence  have  been  named,  noli  me  tangere:  some 
are  nearly  white  ;  others  have  a  grayish  ajjpearance  :  some 
retain  the  natural  color  of  the  gum  ;  others  are  of  a  dark 
purple  hue.  Finally,  some  exists  for  years  without  being 
attended  with  any  serious  consequences,  while  others,  in  a 
few  months,  acquire  so  aggravated  a  character  as  to  threat- 
en the  life  of  the  patient. 

CAUSES. 

Tumors  of  the  gums  seldom  arise  spontaneously,  but  are, 
in  most  instances,  the  result  of  local  irritation,  occasioned 
by  the  presence  of  tartar,  decayed  or  dead  teeth,  or  roots  of 


CAUSES   OF   TUMORS   OF   THE   GUMS.  523 

teeth,  but  tlie  character  which  they  assume  is  determined 
by  the  state  of  the  constitutional  health  or  habit  of  body. 
Hence  their  great  variety.  The  same  causes  operating  here 
as  on  other  parts  of  the  body  often  produce  different  effects. 
One  that  would  give  rise  to  the  development  of  a  simple 
morbid  growth  of  the  gums  in  a  person  of  good  health, 
might,  in  one  affected  with  some  constitutional  vice  or  spe- 
cific morbid  tendency,  give  rise  to  a  tumor  of  a  fungoid, 
cartilaginous,  bony,  or  scirrhous  character. 

It  is  thought  by  some  that  morbid  productions  of  this 
sort  are  occasionally  developed,  independently  of  any  local 
cause,  but  this  opinion  does  not  seem  to  be  well  founded, 
and  we  are  disposed  to  believe  that,  if  all  the  circumstances 
connected  with  the  history  of  each  case^,  especially  the  pre- 
vious condition  of  the  teeth,  could  be  accurately  ascertained, 
their  cause  might,  in  most  instances,  be  traced  to  irritation 
of  the  gums,  or  alveolar  membranes,  produced  by  some  un- 
healthy or  crowded  state  of  these  organs,,  or  to  the  presence 
of  salivary  calculus. 

Mr.  Listen,  in  his  practical  surgery,  remarks:  "Very 
many  of  the  tumors  of  the  jaws  are  traceable  to  faulty 
growth  or  position  of  the  teeth,  to  diseases  of  their  bodies, 
or  to  improperly  conducted  ojierations  upon  them."  And, 
in  speaking  of  tumors  of  the  gums,  he  observes  :  "They 
are  caused  by  decay  of  some  part  of  one  or  more  teeth,  of 
the  crown,  neck,  fang,  or  they  may  arise  from  their  being 
crowded  or  misplaced."  A  crowded  arrangement  of  the 
teeth,  is  always  productive  of  more  or  less  irritation  to  the 
alveolo-dental  periosteum. 

We  do  not,  however,  conceive  it  necessary  to  the  produc- 
tion of  tumors,  that  any  of  the  causes  here  enumerated 
should  exist  at  the  time  they  make  their  appearance.  The 
gums  and  alveoli  having  been  once  affected,  are  ever  after 
more  susceptible  to  morbid  impressions.  It  is,  therefore, 
quite  probable  that  an  unhealthy  action  is  sometimes  con- 
tinued in  them  long  after  the  cause  that  produced  it  ceases 
to  exist ;  and  that  this,  favored  by  a  subsequent  unhealthy 


524 


TREATMENT  OF  TUMORS  OF  THE  GUMS. 


action  of  some  other  part,  or  of  the  system  generally,  deter- 
mines their  development.  When  we  consider  how  often, 
and  almost  constantly,  the  gums  and  alveolar  periosteum 
are  exposed  to  irritation_,  from  the  causes  just  mentioned, 
we  must  admit,  that  this  hypothesis  is  supported  by  a  high 
degree  of  probability.  No  one  we  think,  will  pretend 
to  deny,  that  the  maxilla  and  gums  suffer  more  from  local 
irritation  than  any  of  the  other  parts  of  the  body  ;  and  to 
this  irritation,  we  are  firmly  persuaded  most  of  their  dis- 
eases are  to  be  ascribed. 


TREATMENT. 

The  most  common  form  of  morbid  growth  met  with  in 
the  mouth,  is  that  which  resembles  in  structure  the  gums, 
except  that  it  is  usually  rather  more  vascular.  Tliis  de- 
scription of  tumor  is  always  the  result  of  dental  irritation, 
and  usually  disappears  soon  after  the  removal  of  the 
cause. 

In  1828,  the  author  was  consulted  by  a  gentleman  who 
had  a  considerable  enlargement  of  the  gums,  which  had  fol- 
lowed an  attempt  to  extract  the  first  superior  molar  of  the 
left  side.  In  the  operation  the  two  buccal  roots  were  frac- 
tured and  left  in  their  sockets.  For  fifteen  or  twenty  days 
after  the  accident,  he  experienced  considerable  pain,  but  at 
the  expiration  of  this  period,  it  had  entirely  subsided. 
About  two  months  after,  however,  it  was  again  experienced, 
and  although  the  gum  had  grown  over  the  roots,  it  was  sore 
to  the  touch,  and  soon  began  to  assume  a  bulbous  form, 
gradually  increasing  in  size,  until  at  the  expiration  of  twelve 
months,  when  we  saw  the  patient,  the  tumor  had  attained 
the  size  of  a  black  walnut,  and  was  attached  by  a  broad  base. 
As  it  was  situated  immediately  over  the  fractured  roots  left 
in  the  socket,  we  advised  the  removal  of  the  tumor  previous- 
ly to  attempting  their  extraction.  To  this  he  most  positive- 
ly refused,  but  readily  consented  to  the  removal  of  the  roots. 

In  the  performance  of  this  operation,    about  one-third  of 


TREATMENT  OF  TUMORS  OP  THE  GUMS.         52S 

the  base  was  cut  away,  and  the  remaining  part  of  the  tumor 
sloughed  oif  in  a  few  days. 

Mr.  Fox  relates  the  case  of  a  lady  who  had  an  enlarge- 
ment of  the  gums  that  almost  entirely  filled  up  one  side  of 
her  mouth.  She  first  applied  to  Sir  Astley  Cooper,  who  sent 
her  to  Mr.  F.  to  have  several  decayed  roots,  at  the  base  of  the 
tumor,  extracted,  before  he  should  attempt  its  extirpation. 
The  fangs  being  imbedded  in  the  gums,  the  excrescence  was 
much  lacerated  in  their  removal  ;  afterwards  it  became  pla- 
cid, assumed  a  dark  color,  and  in  a  short  time  sloughed  off. 
Thus  a  perfect  cure  was  effected  without  any  other  operation 
than  that  of  the  extraction  of  the  decayed  roots. 

This  tumor,  it  would  seem,  partook  somewhat  of  a  fun- 
goid character,  and  excrescences  of  this  description  are 
usually  more  difficult  to  cure  than  those  which  consist  of  a 
mere  simple  growth  of  the  gums,  like  the  one  first  noticed. 
Although  they  sometimes  disappear  spontaneously,  on  the 
removal  of  the  exciting  cause,  yet,  in  most  cases,  extirpa- 
tion becomes  necessary,  and  even  this,  when  not  performed 
in  the  most  perfect  manner,  is  not  always  successful.  After 
the  removal  of  one,  another  has  been  known  to  spring  up 
in  its  place;  and  thus  several  have  sometimes  appeared  in 
quick  succession. 

Mr.  Hunter  attributes  the  disposition  of  a  tissue  to  re- 
produce excrescences  of  this  kind,  to  a  scirrhous  tendency 
of  the  parts  from  which  they  originate,  but  a  tumor  will 
rarely  re-appear,  if  the  diseased  structure  be  completely 
removed. 

Mr.  Fox  recommends  that  excrescences  of  this  sort  should 
be  extirpated  by  means  of  ligature,  with  the  assurance  that 
when  thus  removed,  a  second  operation  is  seldom  necessary. 
Excision  is  often  attended  with  profuse  and  obstinate 
hemorrhage,  and,  on  this  account,  the  operation  recom- 
mended by  Mr.  F.  is,  in  most  cases,  preferable.  The  base 
of  some  tumors,  however,  is  so  broad,  that  a  ligature  can- 
not be  applied  sufficiently  low  to  include  the  whole  struc- 
ture.    In  such  cases  we  must  resort  to  excision,  and  if  the 


526 


TREATMENT  OF  TUMORS  OF  THE  GUMS. 


hemorrhage  cannot  he  stopped  hy  compresses,  the  actual 
cautery  may  be  employed. 

Mr.  Hunter  in  treating  of  morhid  growths  of  soft  parts, 
observes:  "Arteries  going  to  increased  parts  are  themselves 
increased,  and  have  not  the  contractile  power  of  a  sound 
artery : ' '  hence  when  wounded,  they  bleed  more  freely  than 
those  that  are  in  a  healthy  state." 

The  removal  of  excrescences  of  the  gums  by  means  of 
ligatures,  not  being  attended  with  so  much  hemorrhage, 
and  also  usually  exterminating  them  more  effectually  than 
excision,  determined  Mr.  Fox  in  his  choice  of  this  mode  of 
operating.  In  treating  of  this  subject,  he  remarks:  "I  de- 
termined, some  years  since,  that  if  any  case  of  this  kind 
should  ever  come  under  my  care,  I  would  attempt  the  re- 
moval by  means  of  ligatures.  The  first  case  in  which  I  was 
consulted,  was  a  lady  of  about  forty  years  of  age,  who  had 
several  of  the  teeth  on  the  right  side  of  the  upper  jaw  ex- 
tracted when  she  was  a  young  woman ;  about  five  years  be- 
fore I  saw  her,  the  gums  covering  the  jaw  where  the  teeth 
had  been  situated,  appeared  to  be  thicker  than  before ;  they 
gradually  increased  in  size  until  a  very  large  tumor  was 
formed;  it  had  now  become  so  large  as  to  affect  the  speech, 
and,  in  other  respects,  was  extremely  troublesome. 

"The  lady  was  very  desirous  to  have  it  removed;  to  effect 
which,  without  incurring  the  danger  of  hemorrhage,  I  em- 
ployed ligatures,  close  to  the  jaw-bone,  through  the  sub- 
stance of  the  tumor,  half  of  which  was  then  included  in 
each  ligature.  The  ligatures  were  tied  just  tight  enough  to 
stop  the  circulation ;  the  next  day  there  was  a  great  deal  of 
inflammation,  which  subsided  in  proportion  as  the  ligature 
began  to  produce  ulceration,  which,  on  the  fourth  day  was 
very  considerable ;  new  ligatures  were  then  applied ;  on  the 
sixth  day  these  were  removed,  and  others  introduced ;  on 
the  eighth,  one  ligature  came  away,  leaving  the  tumor 
hanging  only  by  a  small  peduncle;  this  being  cut  through 
with  a  lancet,  the  whole  was  removed. 

Even  when  the  base  is  large,  the  tumor  may  be  often  sue- 


TREATMENT  OF  TUMORS  OP  THE  GUMS.        527 

cessfiilly  removed  by  passing  a  needle,  armed  with  a  double 
ligature,  through  it,  close  to  the  bone,  and  tying  it  on  each 
side  sufficiently  tight  to  cut  off  the  circulation  between  it 
and  the  general  system ;  and  it  should  be  reapplied  as  often 
as  it  comes  away,  until  the  tumor  has  sloughed  off,  when 
the  place  should  be  touched  with  diluted  nitrous  acid  or  with 
a  solution  of  nitrate  of  silver. 

Cartilaginous  excrescences  of  the  gums  and  alveolar  pro- 
cesses are  comparatively  of  rare  occurrence,  and  are  more 
difficult  to  remove  than  fungous  tumors,  or  those  which  con- 
sist merely  of  a  preternatural  growth  of  the  gums.  The 
hardness  of  their  substance  is  such,  that,  in  many  cases, 
their  removal  by  ligature  is  impracticable,  and  extirpation 
with  the  knife  is,  also,  sometimes,  exceedingly  difficult  and 
tedious.  Besides,  the  operation  of  excision  is  often  followed 
by  obstinate  hemorrhage. 

Ambrose  Pare,  with  no  small  self-gratulation^  talks  of 
having  removed  them  when  they  were  so  large  that  they 
came  out  of  the  mouth,  giving  a  most  hideous  appearance 
to  the  face,  and  when  no  other  surgeon  dared  to  undertake 
their  cure,  because  of  the  lividity  of  their  color.  "This 
lividity,"  says  he,  "I  did  not  fear,  but  I  had  the  boldness 
to  cut  and  even  to  cauterize  the  tumors  until  the  disease  was 
entirely  cured."* 

Jourdain,  in  speaking  of  cartilaginous  excrescences,  re- 
marks: "About  thirty-six  years  ago,  I  was  called,  with 
AUertius  Baringue,  surgeon,  to  see  a  Avoman  that  had  a  tu- 
mor of  a  large  size  situated  on  the  gum  of  the  molar  teeth. 
It  occasioned  her  mouth  to  be  drawn  to  the  opj)osite  side  of 
her  face  when  she  was  seized  with  spasms.  We  advised 
her  not  to  delay  too  long  in  having  it  removed  ;  to  this  she 
would  not  consent,  but,  in  a  short  time,  finding  that  the  ex- 
crescence increased  so  fast,  and  in  such  a  manner  that  it 
hindered  her  from  taking  food,  she  changed  her  mind.  The 
tumor  was  embraced  with  a  brass  wire,  which  we  tightened 
every  day.     The  excrescence,  receiving  nothing  now  to  aug- 

*  Lib.  chap,  viii,  v.  1,  p.  188. 


528  TREATMENT   OF   TUMORS   OF  THE   GUMS. 

ment  its  growtli,  fell,   and,   upon  examination,  we  found 
that  it  was  altogether  cartilaginous."* 

Dr.  Fitch  quotes  a  case  from  Luzitanous,  in  which  the 
operation  for  the  removal  of  the  tumor  was  followed  by  a 
fatal  hemorrhage.  The  tumor  is  described  as  being  about 
half  the  size  of  a  hen's  egg,  exhaling  a  fetid  odor,  and  be- 
ing very  painful.  He  also  mentions  a  case  of  a  somewhat 
similar  character,  that  came  under  his  own  observation. 
'^The  tumor  occupied  the  space  of  the  four  incisor  teeth  of 
the  upper  jaw.  The  teeth  were  all  carious.  I  extracted 
them.  The  tumor  had  four  fistulous  openings,  which  ran 
in  the  direction  of  each  tooth,  and  which  furnished  to  each 
a  fetid  humor.  With  the  actual  cautery  well  heated  in  fire 
and  double-edged,  I  made  but  one  wound  of  the  four  fistu- 
lous openings;  I  touched  the. bone  that  was  carious,  which 
v/as  repeated  several  times  in  the  space  of  three  months. 
In  proportion  as  the  exfoliations  were  made,  the  tumor 
diminished.  The  patient  was  cured  near  the  end  of  the 
fourth  month."! 

When  the  base  of  the  tumor  is  very  broad,  and  the  bone 
beneath  carious,  as  in  the  case  described  by  Dr.  Fitch,  the 
actual  cautery  is,  without  doubt_,  the  surest  remedy,  because 
it  is  obvious  that  until  the  diseased  bone  is  exfoliated,  a  cure 
can  never  be  effected.  But  under  no  circumstances  is  the 
use  of  it  advisable. 

Tumors  originating  in  the  alveolar  processes  or  periosteum, 
are  generally  of  an  osteo-sarcomatous,  or  cartilaginous  char- 
acter. Their  removal  in  either  case  is  more  difficult  than 
that  of  fungous  excrescence.     The  cure  is  also  less  certain. 

Mr,  Bell  has  given  the  history  of  two  cases  of  tumors  of 
the  gums  and  alveolar  processes.  One  of  them,  however, 
he  says,  had  no  connection  with  the  alveolar  processes,  and 
the  other  succeeded  to  an  attack  of  the  tooth-ache  which 
had  lasted  several  months. 

A  case  of  osteo-sarcomatous   tumor,  occasioned   by  dis- 

*  Jourdain,  vol.  2,  p.  334. 

t  Fitch's  Dental  Surgery,  p.  237. 


TREATMENT   OF   TUMORS   OF   THE   GUMS.  529 

eased  teeth,  is  recorded  by  Bordenave.  Sir  Astley  Cooper 
gives  the  history  of  two  cases  of  a  like  nature.  In  one  the 
tumor  originated  in  the  alveolar  cavities,  and  as  it  increased, 
displaced  the  teeth ;  in  the  other  case  the  tumor  was  pro- 
duced by  diseased  teeth.  Dr.  Gibson,  also,  mentions  a  case 
of  osteo-sarcomatous  tumor,  which,  ' 'according  to  the  pa- 
tient's account,  first  appeared  seven  months  before,"  (the 
time  he  first  saw  her,)  ''in  the  form  of  a  small  lump,  seated 
in  the  gum  above  the  canine  tooth." 

In  the  treatment  of  tumors  originating  from  the  gums, 
or  alveolar  processes,  or  from  both,  much  depends  on  their 
character  and  the  constitutional  symptoms  accompanying 
them.  Some  may  be  dispersed  by  simply  extracting  a  de- 
cayed tooth  or  root;  others  will  require  extirpation,  and,  in 
some  instances,  even  this  will  not  avail.  In  short,  the 
treatment  must  be  varied  to  suit  the  respective  circumstances 
of  the  case.  ■  l^<.(2c4. 

It  sometimes  hapj)ens,  when  an  operation  has  been  per- "/C*---^ 
formed  successfully,  so  far  as  regards  the  local  disease,  that  the  '*  '^"'^ 
lungs,  or  some  other  vital  organ,  becomes  affected.  To  pre- 
vent this,  it  is  often  necessary  to  get  up,  by  means  of  a  seton, 
artificial  irritation  in  some  neighboring  part.  Without 
this  precaution,  the  life  of  the  patient  would  often  be  put  in 
as  great  danger  as  that  from  which  it  had  escaped  by  the 
removal  of  the  local  disease. 

On  the  extirpation  of  the  fungous  exostosis,  or  osteo-sar- 
coma,  Sir  Astley  Cooper  observes:  "The  operation,  after 
constitutional  means  have  been  employed_,  and  the  continu- 
ance of  these  means  after  the  operation,  hold  out  the  chief 
hopes  of  safety ;  for  amputation  without  these,  will  do  no 
more  than  avert  the  blow  for  a  season." 

These  remarks  will  be  found  applicable  to  the  treatment 
of  the  same  description  of  disease,  in  whatever  part  of  the 
body  it  may  be  situated.  The  constitutional  symptoms 
should  never  be  disregarded. 


CHAPTER     SIXTH. 

ALVEOLAR    ABSCESS. 

As  most  of  the  plienomena  attending  the  formation  of 
alveolar  abscess  were  noticed  in  the  chapter  on  tooth-ache, 
it  will  not  be  necessary,  in  this  place  to  dwell  upon  them  at 
much  length.  The  periosteum  of  a  tooth  having  become 
the  seat  of  acute  inflammation,  plastic  lymph  is  effused  at 
the  extremity  of  the  root.  This  is  condensed  into  a  sac  or 
cyst,  which  closely  embraces  the  root  near  its  apex,  and  as 
suppuration  takes  place,  pus  is  formed  in  its  centre.  The 
inflammation,  in  the  meantime,  having  extended  to  the 
gums  and  neighboring  parts,  they  swell  and  become  painful^ 
and  as  the  pus  accumulates  in  the  sac,  it  distends  and 
presses  upon  the  surrounding  walls  of  the  alveolus,  which 
by  a  sort  of  chemico-vital  process,  are  gradually  broken 
down.  By  this  means,  an  opening  is  ultimately  made 
through  one  side  of  the  socket,  when  the  pus,  coming  in 
contact  with  the  investing  soft  structures,  presses  U|)on 
them  and  causes  their  absorption.  Thus  an  outlet  is  effect- 
ed for  the  escape  of  the  accumulated  matter. 

The  opening  which  gives  egress  to  the  pus,  is  usually  in 
the  gum  opposite  the  extremity  of  the  root,  but  the  matter 
may  escape  from  some  other  and  more  remote  point.  It  may 
make  for  itself  an  opening  through  the  cheek,  or  through  the 
base  of  the  lower  jaw,  and  be  discharged  externally;  or  it 
may  pass  up  into  the  maxillary  sinus,  or  through  the  nasal 
plates  of  the  superior  maxilla,  or  form  a  passage  between 
the  two  plates  of  the  bone,  and  escape  from  the  centre  of 
the  roof  of  the  mouth. 

The  formation  of  abscess  in  the  alveolus  of  an  inferior 


ALVEOLAH  ABSCESS.  531 

dens  sapientias,  is  sometimes  attended  with  inflammation 
and  swelling  of  the  tonsils  and  of  the  muscles  of  the  cheek 
and  neck.  The  author  has  known  trismus  to  result  from 
this  cause. 

The  pain  attending  the  formation  of  alveolar  abscess,  is 
deep  seated,  throbbing,  and  often  so  excruciating  as  to  be 
almost  insupportable.  But  as  soon  as  suppuration  takes 
place,  it  loses  its  severity,  and  with  the  escape  of  the  pus 
ceases  altogether,  or  very  nearly,  but  the  tooth,  from  the 
thickened  condition  of  the  alveolo-dental  periosteum,  par- 
ticularly at  the  apex  of  the  root,  often  remains  sore  and  sen- 
sitive to  the  touch  for  several  days.  The  energies  of  the 
disease,  however,  having  been  expended,  the  secretion  of 
pus,  in  the  majority  of  cases,,  wholly  ceases,  and  the  opening 
in  the  gums  closes.  But  from  the  increased  susceptibility  in 
the  alveolo-dental  periosteum  to  morbid  impression,  occa- 
sioned by  the  j)resence  of  a  tooth  deprived  of  a  very  large 
portion,  at  least,  of  its  vitality,  a  recurrence  of  the  inflam- 
mation is  liable  to  take  place,  when  pus  will  be  again  formed 
and  the  passage  for  its  escape  re-established.  But  the  pain 
attending  any  subsequent  attack,  is  seldom  so  severe  as  in 
the  first  instance. 

There  are  some  cases,  however,  in  which  the  inflamma- 
tion, instead  of  subsiding  altogether,  degenerates  into  a 
chronic  form.  In  this  case^  the  sac  at  the  extremity  of  the 
root  continues  to  secrete  pus,  though  the  quantity  is  usually 
small,  and  the  opening  in  the  gums  remains  unclosed. 
FiQ.  148.       Fig.  149.  In  the  extraction  of  a  tooth  which 

has  given  rise  to  the  formation  of  ab- 
scess, the  sack  is  often  brought  away 
with  it.  Two  teeth  taken  from  the 
upper  jaw,  one  a  cuspid,  and  the  other 
a  first  molar,  are  represented  in  the 
accompanying  cuts.  Figs.  148  and  149, 
where  this  had  happened.  In  the 
case  of  the  molar,  the  sac  is  attached 
to  the  palatine  root.     Both  of  these  teeth  were  extracted 


532  TREATMENT   OF   ALVEOLAR   ABSCESS. 

previously  to  the  formation  of  an  external  opening  for  tlie 
escape  of  the  matter. 

The  time  required  for  the  formation  of  alveolar  abscess, 
varies  from  three  to  ten  or  fifteen  days,  according  to  the 
violence  of  the  inflammation.  But  a  collection  of  pus  may 
he  detected  by  fluctuation  under  the  finger,  if  applied  to  the 
tumefied  gum,  one  or  two  days  before  an  external  opening 
is  spontaneously  formed  for  its  escape. 

The  inflammation  and  pain  attending  the  formation  of 
abscess,  in  the  socket  of  a  tooth,  often  give  rise  to  general 
febrile  symptoms,  headache  and  constipation  of  the  bowels. 

CAUSES. 

The  immediate  cause  of  alveolar  abscess  is  inflammation 
of  the  alveolo-dental  periosteum,  and  this  may  arise  from 
inflammation  and  suppuration  of  the  lining  membrane  and 
pulp,  or  from  an  accumulation  of  purulent  matter  at  the 
extremity  of  the  root,  the  egress  of  which,  through  the  nat- 
ural opening,  having  been  prevented.  It  may  also  be  pro- 
duced by  mechanical  violence,  or  the  irritation  of  a  dead 
tooth. 

TREATMENT. 

The  treatment  of  alveolar  abscess,  should  be  preventive, 
rather  than  curative,  for  it  rarely  happens,  after  it  has 
occurred,  that  the  integrity  of  the  parts  is  so  perfectly  re- 
stored, as  to  prevent  a  recurrence  of  the  afiection.  Although 
the  secretion  of  pus  may  cease  for  a  time,  and  the  opening 
in  the  gums  become  obliterated,  the  tooth  being  deprived  of 
a  large  portion  of  its  vitality,  is  liable,  whenever  the  excita- 
bility of  the  alveolo-dental  periosteum  is  increased  by  any 
derangenent  of  the  general  system,  to  give  rise  to  a  recur- 
rence of  the  disease.  The  formation  of  abscess,  therefore, 
should,  if  possible,  be  jirevented  by  the  use  of  saline  cathar- 
tics, the  application  of  leeches  to  the  gums,  and  a  cooling 


TREATMENT   OF   ALVEOLAR   ABSCESS.  533 

regimen.  By  prompt  antiphlogistic  treatment  the  inflam- 
mation may  sometimes  be  arrested.  But  sliould  these  means 
fail  to  prevent  the  formation  of  pus,  the  tooth,  unless  its 
retention  is  called  for  by  some  peculiar  necessity,  should  at 
once  be  removed.  If,  however,  as  is  often  tlie  case,  the 
patient  will  not  submit  to  the  operation,  the  escape  of  the  pus 
through  the  gum  should  be  promoted  by  warm  fomentations 
to  the  mouth.  As  soon  as  fluctuation  can  be  perceived  by 
applying  the  finger  to  the  tumefied  gum,  an  opening  may 
be  made  with  a  sharp  lancet  for  the  escape  of  the  matter. 
After  this  has  discharged  itself,  the  swelling  of  the  gums 
and  neighboring  parts  soon  subside. 

The  application  of  fomentations  and  emolient  poultices 
externally,  are  rarely  productive  of  any  advantage,  and 
may  do  harm  by  promoting  the  discharge  of  matter  through 
the  cheek  or  lower  part  of  the  face.  When  this  occurs,  a 
depression  with  puckering  of  the  skin  is  apt  to  remain  after 
the  escape  of  pus  through  the  opening  ceases  and  the  orifice 
has  closed,  causing  disfiguration  of  the  face.  A  very  singu- 
lar case  of  fistulous  opening  through  the  external  integu- 
ments is  mentioned  by  Mr.  Thomas  Bell.  It  had  resulted 
from  an  abscess  in  the  socket  of  the  right  inferior  dens 
sapientiae,  and  the  discharge  of  matter  had  been  kept  up  for 
two  years  before  he  saw  the  patient.  ''At  this  time,"  says 
Mr.  B.,  "a  funnel-shaped  depression  existed  in  the  skin, 
which  could  be  seen  to  the  depth  of  nearly  three-quarters  of 
an  inch,  and  a  small  probe  could  be  passed  through  it  into 
the  sac  of  the  abscess,  underneath  the  root  of  the  tooth. 
The  abscess  had  now  remained  open  for  two  years,  during 
the  latter  of  which,  the  parts  had  been  in  the  state  I  have 
described.  I  removed  the  tooth,  and  as  I  anticipated,  no 
farther  secretion  of  pus  took  place  ;  but  so  perfectly  had  the 
communication  been  established,  that  when  the  gum  healed, 
it  left  by  its  contraction,  a  fistulous  opening,  through  which 
a  portion  of  any  fluid  received  into  the  mouth  passed  readily 
to  the  outside  of  the  cheek ;  and  I  could  with  care,  intro- 
duce a  fine  probe  completely  through  the  passage.     So  free, 


534  TREATMENT   OF   ALVEOLAR   ABSCESS. 

in  fact  was  the  communication,  that  some  of  the  hairs  of 
the  whiskers,  with  which  the  external  portion  of  the  depres- 
sion was  filled,  grew  through  the  internal  opening,  and 
appeared  in  the  mouth. 

"I  passed  a  very  fine  knife,  resembling  the  couching 
needle,  through  it,  and  removed  as  perfectly  as  possible,  a 
circular  portion  of  the  parietes  of  the  tube  towards  the  gum  ; 
but  failed  in  this,  and  several  other  attempts,  to  produce  a 
union.  It  was,  therefore,  resolved  that  the  whole  parietes 
of  the  depression  should  be  removed,  extending  the  incision 
as  far  internally  as  possible;  and  the  integuments  thus 
brought  together  as  a  simple  wound.  In  consequence, 
however,  of  the  suppuration  of  a  small  gland  in  the  imme- 
diate neighborhood,  the  operation  was  deferred  until  that 
should  have  been  dispersed,  and  it,  therefore,  remains  at 
present  in  the  state  in  which  I  have  described  it." 

It  rarely  happens,  however,  that  anything  more  is  neces- 
sary for  the  cure  of  the  external  opening  than  the  extrac- 
tion of  the  tooth  which  had  given  rise  to  the  formation  of 
the  abscess.  The  author  has  been  consulted  in  many  cases, 
and  has  never  found  it  necessary  to  resort  to  other  means, 
but  should  the  external  opening  remain,  the  wall  of  the 
tube  and  depression  may  be  removed  in  the  manner  as  just 
described. 

The  formation  of  an  abscess  in  the  alveolus  of  a  lower 
wisdom  tooth,  is  sometimes  productive  of  very  serious  and 
even  alarming  consequences.  The  following  is  one  of  seve- 
ral cases  of  the  kind  which  have  fallen  under  the  observa- 
tion of  the  author. 

In  1832,  he  was  sent  for  in  great  haste  to  visit  a  physi- 
cian Dr.  E.,  who  resided  thirty  miles  in  tlie  country.  The 
doctor  had  been  attacked  two  weeks  before  with  severe  pain 
in  the  left  dens  sapientiaB  of  the  lower  jaw.  At  the  expira- 
tion of  three  or  four  days,  a  physician  was  called  in  who 
made  several  unsuccessful  attempts  to  extract  the  tooth. 

Tlie  inflammation  now  extended  rapidly  to  the  fauces, 
tonsils  and  muscles  of  the  jaw  and  face.     Obstructed  deglu- 


TREATMENT   OF   ALVEOLAR   ABSCESS.  535 

tion  and  intractable  fever  soon  supervened.  Repeated 
blood-lettings^  cathartics,  and  fomentations  to  the  face  were 
resorted  to  with  little  effect.  His  respiration  was  difficult 
and  the  muscles  of  his  jaws  soon  became  so  rigid  and  firmly 
contracted  that  his  mouth  could  not  be  opened. 

This  was  the  condition  of  the  patient  when  the  author 
first  saw  him,  which  was  the  morning  of  the  day  following 
the  one  on  which  he  was  sent  for.  In  addition  to  the  treat- 
ment which  liad  previously  been  pursued,  an  injection  with 
two  grains  of  emetic  tartar  was  administered.  About  seven 
o'clock  in  the  evening,  the  fever  was  succeeded  by  alternate 
paroxysms  of  cold  and  heat.  An  effort  was  now  made  to 
force  open  his  mouth,  with  a  wooden  wedge.  This  was  par- 
tially successful,  but  his  teeth  could  not  be  forced  asunder 
sufficiently  to  admit  of  the  introduction  of  the  smallest  sized 
tooth-forceps.  But  while  his  jaws  were  thus  partially  sepa- 
rated, he  attempted  to  swallow  some  warm  tea;  in  the 
effort  an  abscess  bursted  and  discharged  nearly  a  table- 
spoonful  of  pus  from  his  mouth,  and  it  was  supposed  that 
double  that  quantity  passed  down  into  his  stomach.  This 
gave  immediate  relief,  but  it  Avas  not  until  about  three 
o'clock  in  the  afternoon  of  the  next  day  that  his  jaws  could 
be  forced  apart  sufficiently  to  permit  the  extraction  of  the 
tooth  which  had  caused  the  trouble.  To  the  roots  of  this, 
which  were  united,  there  was  a  sac  about  the  size  of  a  large 
pea,  filled  with  pus.  The  patient  recovered  rapidly,  and 
in  a  few  days  was  quite  well. 

The  following  is  the  most  singular  case  of  alveolar  abscess 
which  has  ever  fallen  under  the  observation  of  the  writer  : 
The  subject  was  a  lady  of  about  thirty  years  of  age.  She 
had  been  troubled  with  a  dripping  of  pus  from  behind  the 
curtain  of  the  palate  for  about  twelve  months,  and  becoming 
somewhat  alarmed  at  its  continuance,  she  called  the  atten- 
tion of  her  family  physician.  Prof.  Bond,  to  it,  who,  after 
having  carefully  examined  the  case,  endeavored  to  ascertain 
the  place  from  whence  tlie  matter  came.  He  soon  satisfied 
himself  that  it  was  from  the  socket  of  a  diseased  tooth,  and 


536  TREATMENT  OF   ALVEOLAR   ABSCESS. 

after  passing  liis  finger  around  on  the  gums  covering  the  su- 
perior alveolar  border,  discovered  a  protuberance  over  the 
root  of  each  upper  central  incisor,  nearly  as  large  as  a  hazel- 
nut. This  tended  to  confirm  the  opinion  which  he  had 
formed  with  regard  to  the  place  from  whence  the  matter 
came^  and  he  requested  the  writer  to  visit  the  lady  witli  him, 
which  he  did  on  the  following  day.  On  examining  the  case 
he  advised  the  immediate  removal  of  the  affected  teeth,  and 
the  more  strongly  as  they  were  found  to  be  in  a  necrosed 
condition. 

The  lady  readily  consented  to  the  operation,  which  was 
performed  on  the  following  day.  The  discharge  of  matter 
from  behind  the  curtain  of  the  palate  immediately  ceased, 
and  the  patient  was  thus  relieved  from  an  affection  which 
had  been  a  source  of  great  annoyance.  The  pus  from  the 
abscess,  in  this  case,  instead  of  passing  out  through  the 
nasal  plates  of  the  superior  maxilla,  passed  back  over  the 
roof  of  the  mouth,  and  escaped  in  the  manner  as  de- 
scribed."* 

Since  the  publication  of  the  fourth  edition  of  this  work, 
the  author  was  consulted  in  a  case  of  a  similar  character  to 
the  one  last  noticed.  The  pus,  however,  had  escaped  from 
the  socket  of  a  first  superior  molar,  to  about  the  centre  of 
the  palatine  arch,  thence  passed  up  into  the  posterior  nares 
and  was  discharged  from  behind  the  velum  palati. 

Inflammation  of  the  investing  membrane  of  the  roots  of 
an  inferior  dens  sapientite  may  produce  equally  serious 
effects,  without  occasioning  the  formation  of  an  abscess  in 
the  alveolus.  The  eruption  of  these  teeth  are_,  sometimes, 
attended  with  like  consequences.  The  irritation  has,  in 
some  instances,  extended  to  the  lungs  and  produced  con- 
sumption. 

The  occurrence  of  alveolar  abscess  in  the  socket  of  a  tem- 
porary tooth,  is  often  followed  by  exfoliation  of  the  sockets 


*  Vide  addition  by  the  author  to  American  edition  of  "The  Natural  History  and 
Diseases  of  the  Human  Teeth,"  by  Joseph  Fox,  pp.  282-.3, 


TREATMENT   OF   ALVEOLAR   ABSCESS.  SSY 

of  several  teeth,  and  sometimes  of  considerable  portions  of 
the  jaw-bone,  seriously  injuring  the  rudiments  of  the  per- 
manent teeth,  and  sometimes  causing  their  destruction. 
The  author  saw  a  case,  a  few  years  since,  in  which  an  abscess 
of  the  alveolus  of  the  first  lower  temporary  molar  had  occa- 
sioned exfoliation  of  the  sockets  of  a  cuspid  and  two  molars. 
About  one-half  of  the  alveolar  cells  of  the  two  bicuspids 
and  the  cuspid  of  the  second  set,  were  also  exfoliated — thus 
leaving  their  imperfectly  formed  crowns  entirely  exposed. 

When  the  inflammation  of  the  alveolo-dental  periosteum 
results  from  inflammation  of  the  pulp  and  lining  membrane, 
the  formation  of  abscess  may  be  prevented  by  the  prompt 
destruction  of  the  latter  with  arsenious  acid,  cobalt  or  chlo- 
ride of  zinc.  If  an  attempt  is  to  be  made  to  secure  the  pre- 
servation of  the  tooth,  this  should  be  done,  as  the  chances  of 
success  are  always  greater  previously  to  the  formation  of  an 
abscess  than  afterwards.  But  for  a  description  of  the  method 
of  procedure  in  a  case  of  this  kind,  the  reader  is  referred  to 
the  chapter  on  filling  the  pulp-cavities  and  roots  of  teeth. 


35 


CHAPTER      SEVENTH. 

NECROSIS  AND   EXFOLIATION  OF   THE  ALVEOLAR   PRO- 
CESSES. 

The  alveolar  processes,  as  well  as  other  osseous  structures, 
are  liable  to  necrosis  or  loss  of  vitality.  When  their  con- 
nection with  the  periosteum — the  source  from  whence  they 
derive  their  nourishment  and  vitality — is  destroyed,  death 
follows  as  a  necessary  consequence.  The  loss  of  vitality  may 
be  confined  to  the  socket  of  a  single  tooth,  but  more  fre- 
quently it  extends  to  several,  and  sometimes  to  the  entire 
alveolar  border,  occasionally  including  a  part  or  the  whole 
of  the  jaw.  It  may  occur  in  either  jaw^  but  it  is  more  liable 
to  take  place  in  the  lower  than  the  upper.  When  confined 
to  the  alveoli,  the  dead  part  is  never  replaced  with  new  bone, 
but  examples  are  on  record  of  the  regeneration  of  a  part, 
and  even  the  whole  of  the  lower  jaw.  It  is,  however,  de- 
nied by  some,  that  the  loss  of  any  portion  of  this  bone  is 
ever  replaced  with  true  osseous  structure. 

When  one  or  more  of  the  sockets  of  the  teeth  lose  their  vi- 
tality, nature  exerts  all  her  energies  to  scjiarate  the  dead  from 
the  living  bone,  a  process  technically  termed  exfoliation,  and 
is  supposed  by  some  to  consist  in  a  sort  of  suppurative  in- 
flammation, but  there  is  good  reason  to  believe  it  is  effected 
by  the  action  of  a  corrosive  fluid  poured  out  from  the  fun- 
gous granulations  of  the  living  bone  in  immediate  contact 
with  the  necrosed  part.  During  the  process  of  exfoliation, 
thin  acrid  matter  is  discharged  from  one  or  more  fistulous 
openings  through  the  gums  or  from  between  them  and  the 
necks  of  the  teeth,  and  this  investing  structure  having  lost 
its  connection  with  the  necrosed  bone,  becomes  soft  and 


NECROSIS   OF  THE   ALVEOLAR   PROCESSES.  539 

spongy,  and  assumes  a  dark  purple  appearance.  It  is  pre- 
ternatiirally  sensitive  to  tlie  touch,  and  bleeds  from  the  most 
trifling  injury. 

In  the  admirable  work  of  Mr.  Fox,  on  the  Natural  His- 
tory and  Diseases  of  the  Teeth,  there  are  two  engravings  of 
exfoliated  alveolar  processes. 

The  first  represents  the  alveoli  of  a  central  and  lateral  in- 
cisor and  that  of  the  left  cuspid,  with  a  portion  of  the  max- 
illa, extending  about  five-eighths  of  an  inch  above  the  apex 
of  the  roots  of  the  last  mentioned  tooth.  The  subject  of 
this  case  was  a  gentleman  whose  left  lateral  incisor  became 
carious  ;  inflammation  and  pain  ensued,  together  with  swell- 
ing of  the  gums  and  lip.  Instead  of  consulting  a  physician 
he  applied  poultices  to  his  face,  until  suppuration  in  the  al- 
veolus took  place,  causing  the  formation  of  an  external  open- 
ing through  the  gums  for  the  discharge  of  the  matter. 
After  his  mouth  had  remained  for  some  time  in  this  condition, 
he  applied  to  Mr.  Fox,  who,  upon  examination,  found  that 
not  only  the  decayed  tooth  had  become  loose,  but  also  one 
on  each  side  of  it.  The  first  he  extracted,  and  discovered 
that  the  alveolus,  from  the  destruction  of  its  periosteum, 
was  quite  rough.  The  adjoining  teeth  still  continuing 
loose,  were  in  a  few  weeks  removed,  and  the  slight  force 
that  was  applied,  brought  with  them  the  alveolar  processes 
of  the  whole  of  the  three  teeth,  and  also  a  considerable  por- 
tion of  the  jaw-bone.  The  other  engraving  represents  an 
inferior  molar  and  two  bicuspids^  with  their  sockets  and  a 
very  large  piece  of  jaw-bone.  The  necrosis  and  exfoliation 
in  this  case,  as  in  the  other^  was  produced  by  alveolar 
abscess. 

The  author  has  met  with  several  very  similar  cases,  though 
all  were  not  produced  by  the  same  cause,  and  he  has  several 
specimens  in  his  possession,  two  of  which  were  presented  him 
by  his  late  brother.  Dr.  John  Harris. 

Since  the  publication  of  the  fourth  edition  of  this  work, 
the  author  has  met  with  two  cases  of  necrosis  and  exfolia- 
tion of  the  filveolnr  processes,  which  arc  Avorthy  of  special 


540  NECROSIS   OF   THE   ALVEOLAR    PROCESSES. 

notice.     The  subject  of  the  first  case,  was  a  gentleman  of  a 
strumous  liabit,    about  thirty  years  of  age,  and  the  necro- 
sis and  exfoliation  extended  to  the  sockets  of  all  the  teeth 
in  the  upper  jaw.     In  May,  1851,  he  had  the  nerve  destroy- 
ed in  the  second  bicuspid,  on  the  right  side  of  the  superior 
maxillary.     We  believe  it  was  afterwards  removed,  and  the 
pulp-cavity  and  root  filled.     About  six  weeks  after,  as  near- 
ly as  we  could  ascertain,  the   socket  of  the  tooth   became 
slightly  painful,,  but  as  his  suffering  was  not  constant,  he 
supposed  it  would  soon  cease.     The  pain  ultimately,  howev- 
er, began  to  increase,  and  by  the  latter  part  of  the  follow- 
ing September  was  so  severe,  and  attended  by  so  much  con- 
stitutional disturbance,  he  was  induced  to  consult  a  physi- 
cian.    After  having  been  under  medical  treatment  for  about 
two  weeks,  the  author  was  requested  by  the  medical  attend- 
ant to  see  him.     The  affected  tooth  was  found  upon  exami- 
nation^ to  be  loose,  and  its  socket  in  a  necrosed  condition. 
Inflammation  had   extended  to  every  j)art  of  the  alveolar 
border  ;  the  gums  were  very  much  swollen,  and  nearly  all 
the  teeth  sensitive  to  the  touch.     As  the  patient  was  laboring 
under  considerable  cerebral  derangement,  and  as  no  advan- 
tage could  be  derived  from  the  removal  of  the  tooth  at  this 
time^  it  was  deemed  advisable  to  let  it  remain  until  exfolia- 
tion of  the  necrosed  socket  should  take  place. 

Without  going  into  a  detailed  description  of  the  local  and 
constitutional  treatment  which  was  subsequently  pursued, 
it  will  be  sufficient  to  state,  that  necrosis  extended  to  the 
sockets  of  all  the  other  teeth,  except  those  of  the  second  and 
third  molars  on  each  side  of  the  mouth.  In  the  course  of 
about  two  months,  twelve  teeth,  together  with  their  exfoli- 
ated sockets,  and  several  large  pieces  of  the  maxillary  bone 
were  removed.  It  was  hoped  the  disease  would  stop  here, 
but  in  three  or  four  weeks,  the  four  remaining  molars  be- 
came very  sore  to  the  touch,  and  as  purulent  matter  began 
to  be  discharged  from  their  sockets,  it  became  necessaiy  to 
remove  them.  Several  small  pieces  of  bone  were  exfoliated 
after  the  last  operation,  but  at  the  expiration  of  about  four 


NECROSIS   OF   THE   ALVEOLAR   PROCESSES. 


541 


montlis  from  this  time,  liis  mouth  was  sufficiently  restored 
to  enable  him  to  wear  a  temporary  set  of  artificial  teeth. 

The  subject  of  the  second  case  was  a  ^'«-  i^o. 

lady  of  a  chachectic  habit,  about  thirty- 
five  years  of  age.  The  necrosis  resulted 
from  inflammation  of  the  alveolo-dental 
periosteum,  occasioned  by  irritation  pro- 
duced by  the  roots  of  the  four  upper  in- 
cisors, upon  which  artificial  teeth  had  been  placed.  These, 
however^  had  been  removed  some  two  or  three  weeks  before 
the  author  saw  the  patient.  At  this  time  the  necrosis  had 
extended  not  only  to  the  sockets  of  these  teethj  but  also  up 
to  the  nasal  crest  of  the  maxillary  bone_,  and  the  process  of 
exfoliation  had  already  proceeded  so  far  that  he  was  enabled 
to  remove  the  entire  piece — the  appearance  of  which  is 
represented  in  Fig.  150.  In  July,  1852,  a  few  weeks  after 
the  removal  of  this  piece,  he  again  saw  the  patient,  and  on 
examination,  found  a  large  portion  of  the  palatine  plate  of 
the  bone  in  a  necrosed  state  but  the  process  of  separation 
had  not  yet  proceeded  far  enough  to  enable  him  to  remove  it. 

The  accompanying  en- 
graving, made  from  a 
drawing  furnished  the  au- 
thor by  Dr.  Maynard,  of 
Washington  City,  repre- 
sents a  case  of  necrosis 
and  exfoliation  of  a  por- 
tion of  the  outer  wall  of  the  alveolar  ridge,  and,  as  a  conse- 
quence, the  protrusion  of  the  roots  of  the  teeth  on  one  side 
of  the  mouth.  Dr.  M.  says,  the  only  facts  which  he  has 
been  able  to  procure  in  relation  to  this  case,  ''are  contained 
in  the  patient's  statement,  'that  in  1818  he  took  a  cold, 
which  settled  in  his  upper  jaw,  and  a  large  piece  of  the  jaw- 
bone came  away.'  The  cast,"  says  Dr.  M.,  "from  which 
the  drawing  was  made,  was  taken  in  1840 — at  which  time 
I  cut  off  the  apices  of  several  fangs  which  projected  from  the 
gums. 


Fig.  151. 


542        TREATMENT   OF  NECROSIS  OF   ALVEOLAR  PROCESSES. 


CAUSES. 

The  immediate  cause  of  necrosis  is  the  death  of  the  peri- 
osteum, occasioned  by  inflammation.  The  causes  of  this, 
as  has  already  been  shown,  are,  in  a  large  majority  of  the 
cases,  dental  irritation.  Necrosis  of  the  alveolar  processes 
occurs  very  frequently  while  the  system  is  under  the  influ- 
ence of  mercurial  medicines^  and  during  bilious  and  inflam- 
matory fevers,  and  certain  other  constitutional  diseases,  as 
syphilis,  small  pox,  etc.  It  may  also  result  from  mechani- 
cal injuries. 

TREATMENT. 

In  the  treatment  of  cases  of  this  kind,  little  can  be  done. 
As  soon,  however^  as  the  dead  portions  of  bone  become  sep- 
arated from  the  living,  and  can  be  easily  removed,  they 
should  be  taken  away  with  a  pair  of  forceps.  To  correct  the 
ofiensive  odor,  and  disagreeable  taste  occasioned  by  the  con- 
stant discharge  of  fetid  matter,  a  wash  of  diluted  chloride 
of  soda,  or  of  the  tinct.  of  myrrh  may  be  employed.  For 
any  other  purpose  than  this,  we  have  not  been  able  to  per- 
ceive that  local  applications  were  of  much  advantage. 
Should  constitutional  symptoms  supervene^  tonics  and  a 
generous  diet  may  be  recommended. 


CHAPTER    EIGHTH. 


GRADUAL  DESTRUCTION  OF  THE  ALVEOLAR  PROCESSES. 


^"'-  ^^^-  While  treating   of  inflammation 

and  tumefaction  of  the  gums,  the 
author  adverted  to  the  wasting  of 
the  sockets  of  the  teeth,  and  he 
then  took  occasion  to  express  a  doubt 
that  such  operation  of  the  economy 
ever  manifested  itself  in  the  absence 
of  all  local  disease. 
It  is  always  accompanied  by  a  slight  increase  of  redness, 
tumefaction  and  ulatrophia  or  shrinking  of  the  edges  of  the 
gums,  but  the  diseased  action  here  is  so  inconsiderable  as  to 
attract  but  little  attention.  It  is  also  attend  by  a  slight 
discharge  of  puriform  matter  from  between  the  margins  of 
the  gums  and  the  teeth,  but  the  quantity  is  so  small  that  it 
usually  escapes  observation.  The  alveolo-dental  jieriosteum 
participates  also  in  the  diseased  action,  but  this  is  so  slight- 
ly affected  that  the  teeth  often  remain  quite  firmly  articu- 
lated after  the  wasting  of  their  sockets  has  proceeded  so  far 
as  to  expose  more  than  half  of  each  of  their  roots.  Indeed 
the  afiection  is  so  closely  allied  to  chronic  inflammation  and 
tumefaction  of  the  gums  as  scarcely  to  deserve  separate  con- 
sideration. 

The  progress  of  the  disease  is  usually  so  slow  that  from 
ten  to  fifteen  or  tAventy  years  are  required  to  afibct  very 
perceptibly  the  stability  of  the  teeth  in  their  sockets.  The 
commencement  of  this  destructive  process  is  usually  first  ob- 
served around  the  cuspid  teeth  ;  but  sometimes  it  makes  its 


544  CAUSES   OF   DESTRUCTION   OF   THE   ALVEOLI. 

first  appearance  on  the  alveoli  of  tlie  palatine  roots  of  the 
first  and  second  ui:)per  molars,  and  occasionally  it  goes  on 
here  for  years  before  it  afiects  the  sockets  of  any  of  the  other 
teeth. 

The  teeth  after  their  roots  have  become  partially  exposed, 
as  might  naturally  be  supposed,  are  more  susceptible  to  im- 
pressions of  heat  and  cold  and  more  easily  affected  by  acids, 
but  this  is  about  the  only  manifest  inconvenience  experienced 
from  the  disease,  until  they  begin  to  loosen  in  their  sockets. 

In  Fig.  152  is  represented  a  case  in  which  the  roots  of  the 
teeth  have  become  considerably  exposed  by  the  gradual 
wasting  of  their  sockets. 

CAUSES. 

The  cause  of  this  peculiar  afiection  has  never  been  very 
satisfactorily  explained.  Some  have  supposed  that,  inas- 
much as  it  occurs  most  frequently  in  persons  of  advanced 
age,  that  it  results  from  a  decline  of  the  vital  powers  of  the 
body,  independently  of  local  causes.  But,  as  it  is  often  met 
with  in  middle-aged  persons  whose  constitutional  health  is 
unimpaired^  we  doubt  the  correctness  of  the  opinion.  The 
teeth,  in  all  the  cases  which  have  come  under  our  observa- 
tion, whether  in  middle-aged  or  very  old  persons,  indicated, 
whatever  may  have  been  the  state  of  the  general  health  at 
the  time,  an  excellent  innate  constitution.  In  every  in- 
stance these  organs  were  possessed  of  great  density,  and  this 
fact  is  i^articularly  noticed  by  Mr.  Fox,  who  says  : 

"In  a  majority  of  cases  in  which  this  disease  occurs,  the 
teeth  are  perfectly  sound,  and  from  numerous  observations, 
we  think  we  may  venture  to  assert,  that  persons  who  have 
had  severai  of  their  teeth  afiected  with  caries  in  the  earlier 
part  of  life,  are  not  liable  to  lose,  by  an  absorption  of  their 
sockets,  those  which  remain  sound  ;  but^  where  the  teeth 
have  not  been  afiected  with  caries  in  the  early  part  of  life, 
persons,  as  they  approach  fifty  years  of  age,  and  often  much 


TREATMENT   OF    DESTRUCTION   OF   THE   ALVEOLI.  545 

earlier,  have  their  teeth  become  loose  from  absorption,  or  a 
wasting  of  the  alveolar  process." 

Now  it  is  evident  that  teeth  endowed  with  the  power  of 
resisting  the  action  of  the  causes  of  decay,  to  which  all  teeth 
are  more  or  less  exposed,  to  so  late  a  period  of  life,  must  be 
possessed  of  extreme  density,  and  necessarily,  a  correspond- 
ingly low  degree  of  vitality.  In  view  of  this  fact,  we  have 
been  led  to  believe  that  the  teeth  themselves  act,  to  some 
extent,  as  mechanical  irritants  to  the  more  highly  vitalized 
parts  with  which  they  are  immediately  connected,  causing 
an  increase  of  vascular  action  in  the  periosteum  of  the  thin 
edges  of  the  alveoli  and  margin  of  the  gums.  This  abnor- 
mal condition  cannot,  we  believe,  be  traced  to  any  other 
cause,  and  the  existence  of  it  evidently  gives  rise  to  the  se- 
cretion of  purulent  matter  observed  between  the  edges  of  the 
gums  and  teeth.  But  whether  this  be  true  or  not,  it  is 
doubtless  to  the  corrosive  action  of  this  purulent  matter  that 
the  gradual  destruction  of  the  alveoli  is  attributable. 

We  were  for  a  long  time  inclined  to  ascribe  the  increase 
of  vascular  action  in  the  edges  of  the  gums  and  alveolo- 
dental  periosteum  to  irritation  produced  by  the  pressure  of 
the  teeth  against  the  intermediary  walls  of  the  alveoli,  but 
having  met  with  many  cases  where  the  teeth  were  not 
croAvded,  we  were  induced  to  enter  into  a  more  thorough 
examination  of  the  cause,  and  the  foregoing  is  the  only  con- 
clusion to  which  we  have  been  able  to  arrive. 

TREATMENT. 

From  what  has  been  said  concerning  the  cause  of  this 
affection,  it  is  obvious  that  a  cure  cannot  be  effected.  The 
secretion  of  the  purulent  matter,  upon  the  chemical  action 
of  which  the  destruction  of  the  alveoli  manifestly  depends, 
being  caused  by  disease  in  the  alveolo-dental  periosteum  and 
edges  of  the  gums,  arising  from  the  physical  condition  of 
the  teeth,  the  most  we  can  hope  to  accomplish  is,  to  retard 
its  progress.     This  can  only  be  done  by  cleaning  the  teeth 


546  TREATMENT   OF   DESTRUCTION   OF   THE   ALVEOLI. 

frequently  and  thoroughly,  using  the  j)recaution  each  time 
to  remove  the  corrosive  matter  from  between  the  edges  of 
the  gums  and  teeth.  For  this  purpose  a  brush  with  elastic 
bristles  should  be  used_,  and  much  benefit  will  be  derived  by 
passing  floss  silk  several  times  a  day  up  and  down  between 
the  teeth. 


CHAPTER    NINTH. 

DISPLACEMENT  OF  THE   TEETH  BY  A  DEPOSIT  OF  OS- 
SEOUS  MATTER   m   THEIR   SOCKETS. 

A  TOOTH  is  sometimes  slowly  forced  from  its  place  by  a 
deposit  of  bony  matter  in  the  bottom  or  on  the  side  of  the 
socket.  Two,  or  even  three  teeth  may  be  gradually  dis- 
placed by  exostosis  of  the  alveoli  at  the  same  time.  The 
deposition  usually  proceeds  so  slowly  that  one  or  two  years 
are  required  to  effect  a  very  perceptible  change  in  the  situa- 
tion of  a  tooth.  The  upper  central  incisors  are  more  fre- 
quently affected  than  any  of  the  other  teeth,  and  the  osseous 
deposit  occurs  oftener  at  the  bottom  than  on  the  sides  of  the 
alveoli.  In  the  first  case,  the  tooth  is  gradually  forced  from 
the  socket,  and  in  the  other,  it  is  either  pressed  against  one 
of  the  adjoining  teeth  or  out  of  the  arch.  Irregularity  in 
the  arrangement  of  the  teeth,  is,  in  this  manner,  sometimes 
produced,  especially,  when  more  than  one  socket  is  affected 
at  the  same  time.  The  central  incisors  are  sometimes  forced 
apart ;  at  other  times  they  are  forced  against  each  other, 
and  caused  to  overlap.  The  deposition  of  bone,  however, 
being  generally  confined  to  the  bottom  of  the  sockets,  the 
teeth  are  more  frequently  thrust  from  their  alveolar  cavities, 
and  when  this  occurs  with  a  person  whose  upper  and  lower 
teeth  strike  plumb  upon  each  other,  it  occasions  much  incon- 
venience ;  for,  the  elongated  tooth  must  either  be  thrown 
from  the  circle  of  the  other  teeth,  or^  by  striking  its  antago- 
nist, prevent  the  jaws  from  coming  together. 


548  TREATMENT   FOR   DISPLACEMENT   OF   THE   TEETH. 


CAUSES. 

So  little  is  known  concerning  the  cause  of  exostosis  of  the 
sockets  of  the  teeth^,  that  it  may  seem  almost  useless  to 
attempt  an  explanation  of  it.  That  it  results  from  irritation 
of  the  lining  membrane,,  is  very  generally  believed,  but  the 
cause  of  this  does  not  seem  to  be  well  understood.  We  have 
thought  that  it  might  sometimes  be  produced  by  pressure  on 
the  bottom  of  the  alveolus,  especially  when  the  extremity  is 
nearly  as  large  as  any  other  part  of  the  root  of  the  tooth. 
But  the  susceptibility  of  the  lining  membrane  to  morbid 
impressions  may  sometimes  be  so  great  that  the  pressure  of 
of  a  very  conical  root  may  be  sufficient  to  produce  this  etFect, 
or,  it  may  be  produced  by  the  pressure  of  a  tooth  which 
possesses  only  a  very  low  degree  of  vitality.  A  diseased 
state  of  the  gums  can  have  no  agency  in  the  production  of 
the  exostosis,  for  it  most  frequently  occurs  in  individuals 
whose  gums  are  perfectly  healthy  ;  and  if  it  were  the  result 
of  any  constitutional  tendency,  all  the  teeth  would  be  as 
likely  to  be  affected  by  it,  as  those  we  have  mentioned. 

TREATMENT. 

When  the  exostosis  is  on  the  side  of  the  alveolar  cavity^ 
the  tooth  cannot  be  restored  to  its  natural  position,  but  when 
it  is  in  the  bottom  of  the  socket,  the  elongated  organ  may 
from  time  to  time,  as  it  is  forced  from  the  alveolus,  be  filed  off 
even  with  the  other  teeth,  but  in  doing  this  care  should  be 
taken  not  to  jar  it.  This  v^ill  remove  the  deformity  and 
prevent  its  displacement  by  the  antagonizing  tooth.  By 
this  simple  operation^  repeated  as  occasion  may  require,  it 
may  be  preserved  for  years,  and  rendered  almost  as  useful  as 
any  of  the  other  teeth. 


I 


PART    FIFTH. 


DISEASES    OF    THE    MAXILLARY    SINUS, 


AND 


THEIR    TREATMENT. 


PA.IIT     FIFTH. 

CHAPT  ER      FIRST. 

PRELIMINARY     REMARKS. 

It  was  not  until  the  knowledge  of  anatomy  had  made 
considerahle  progress  that  the  existence  of  this  cavity  was 
known.  Casserius,  an  anatomist  of  Padua,  who  flourished 
during  the  latter  part  of  the  sixteenth  and  early  part  of 
the  seventeenth  centuries,  is  supposed  to  have  heen  the  first 
to  discover  it ;  but  no  correct  description  of  it  was  given 
until  about  the  middle  of  the  latter,  and  the  credit  of  this 
belongs  to  Nathaniel  Highmore,  author  of  a  treatise  on 
anatomy,  published  in  1651.*  Hence  its  name,  '' aw^rwm 
Mghmorianum. ' ' 

This  cavity  is  subject  to  some  of  the  most  formidable  and 
dangerous  diseases  the  medical  or  surgical  practitioner  is 
ever  called  upon  to  treat ;  and  yet  there  are  few  diseases  in- 
cident to  the  human  body,  that  have  not  received  more  at- 
tention from  writers  on  pathology  and  therapeutics  than 
these.  Diseases  are  sometimes  here  met  with,  over  which 
neither  the  surgeon  nor  physician  can  exercise  any  control, 
and  whose  progress  is  only  arrested  with  that  of  the  life  of 
the  unfortunate  sufferer. 

All  of  the  diseases  to  which  the  antrum  maxillare  is  sub- 
ject, however,  are  not  of  so  dangerous  a  character ;  some  are 
very  simple  and  easily  cured,  but,  even  those  which  are  re- 
garded as  the  least  dangerous,  and  that  yield  most  readily 

*  This  work  is  entitled  "Corporis  Hnmnai  Pcrquisitio  Anatomico." 


552  PRELIMINARY  REMARKS. 

to  treatment^  when  instituted  during  their  incipient  or 
earlier  stages,  often,  if  neglected,  or  improperly  treated, 
assume  a  new  and  so  aggravated  a  form  as  to  bid  defiance 
to  the  skill  both  of  the  ph3^sician  and  surgeon,  "While,  on  the 
one  hand,  the  most  simple  affections  of  this  cavity,  may,  by 
neglect  or  improper  treatment,  ultimately  become  incurable ; 
those  on  the  other,  which  are  considered  the  most  malignant 
and  dangerous  from  their  inception,  might,  we  have  no 
doubt,  by  timely  and  judicious  treatment,  be  effectually  and 
radically  removed.  * 

The  form  which  the  disease  puts  on,  is  determined  by  the 
state  of  the  constitutional  health  or  some  specific  tendency 
of  the  general  system,  and  we  can  readily  imagine,  that  a 
cause  which,  in  one  person,  would  give  rise  to  simple  in- 
flammation of  the  lining  membrane,  or  mucous  engorge- 
ment of  the  sinus,  would,  in  another,  produce  an  ill-con- 
ditioned ulcer,  fungous  hfematodes,  or  osteo-sarcoma. 
Simple  inflammation  and  mucous  engorgement,  not  unfre- 
quently  cause  caries  and  exfoliation  of  the  surrounding 
osseous  tissues^  and,  in  some  instances,  even  the  destruction 
of  the  life  of  the  patient. 

The  importance  of  early  attention  to  the  diseases  of  this 
cavity  is,  therefore,  very  apparent;  and  this  is  the  more 
necessary,  as  it  is  often  difficult,  and  sometimes  even  im- 
possible, to  determine  the  character  of  the  malady,  until  it 
has  progressed  so  far  as  to  have  involved,  to  a  greater  or 
less  extent,  the  neighboring  parts;  when,  if  it  has  not  be- 
come incurable,  its  removal  is,  at  least,  rendered  less  easy 
of  accomplishment.  It  may  be  safely  assumed,  therefore, 
that  in  a  very  large  majority  of  the  cases  of  disease  of  the 
maxillary  sinus,  the  danger  to  be  apprehended  arises  more 
from  neglect  than  any  necessary  fatal  character  of  the 
malady,  so  that  in  forming  a  prognosis,  the  circumstances 
to  be  considered,  are  the  state  of  the  constitutional  health, 
the  progress  made  by  the  affection,  and  the  nature  of  the 
injury  inflicted  by  it  upon  the  surrounding  tissues.  If  the 
general  health   is  not  so  much  impaired  as  to  prevent  its 


PRELIMINARY   REMARKS.  553 

restoration  by  the  employment  of  proper  remedies,  and  the 
neighboring  structures  have  not  become  implicated,  the 
prognosis  will  be  favorable ;  but  if  the  functional  operations 
of  the  body  have  become  very  much  deranged,  and  the  bones 
of  the  face  and  nose  seriously  affected,  the  combined  re- 
sources both  of  medicine  and  surgery  will  prove  unavailing. 

In  young  and  middle  aged  subjects  of  good  constitutions, 
a  morbid  action  may  exist  in  the  antrum  for  years,  without 
giving  rise  to  any  alarming  symptoms,  while  the  same  af- 
fection in  another  less  healthy,  would  rapidly  extend  and 
degenerate  into  so  malignant  a  form  of  disease  as  to  threaten 
the  speedy  destruction  of  the  life  of  the  patient.  Medical 
history  abounds  with  examples  of  this  kind,  and  they  con- 
clusively establish,  that  the  state  of  the  general  health  and 
habit  of  body,  whatever  may  have  been  the  primitive 
characteristics  of  the  malady,  ultimately  determine  its  ma- 
lignancy ;  and  in  the  treatment  of  affections  of  this  cavity, 
as  well  as  other  local  diseases  of  the  body,  the  condition  of 
system  should  not  be  overlooked. 

Independently  of  the  danger  arising  from  the  local  affec- 
tion, diseases  of  the  antrum  are,  for  the  most  part,  very 
loathsome,  and  subject  the  patient  to  great  annoyance. 
They  change  the  qualities  of  its  secretions,  and  cause  them 
to  exhale  a  nauseating,  fetid  odor.  This,  in  many  instances, 
is  almost  insufferable  to  the  patient,  and  when  they  are  pre- 
vented from  escaping  through  the  natural  opening  into  the 
nose,  they  pass  through  an  artificial  one  formed  by  art,  or 
effected  by  their  own  disorganizing  qualities,  through  the 
cheek,  alveolar  border  or  palatine  arch,  always  causing  the 
patient  great  inconvenience. 

The  occurrence  of  disease  in  this  cavity  is  often  very  in- 
sidious. It  not  unfrequcntly  happens  that  it  exists  for 
weeks  and  even  months  before  its  existence  is  susjiected — 
the  slight  uneasiness  being  attributed  to  some  morbid  con- 
dition of  the  teeth  or  gums,  and  the  symptoms  attendant 
upon  one  description  of  affection  are  often  so  similar  to 
those  that  accompany  another,  that  it  is  impossible  to  de- 
36 


554  PRELIMINARY  REMARKS. 

termine  its  true  character  until  it  lias  made  considerable 
progress. 

The  morbid  affections  of  the  maxillary  sinus  are,  for  the 
most  part,  similar  to  those  of  the  nasal  fossfe.  There  is, 
however,  one  form  of  disease  which  seems  to  be  j^eculiar  to 
this  cavity,  viz.  mucous  engorgement.  Deschamps  men- 
tions two,  dropsy  and  purulent  accumulations;*  but  the 
first  of  these,  properly  speaking,  is  never  met  with  in  this 
cavity,  and  authors  who  have  enumerated  it  among  its  dis- 
eases, have  evidently  mistaken  mucous  engorgement  for  it. 
The  fluids  that  accumulate  here  are  of  a  mucous  or  muco- 
purulent character,  except  when  they  are  the  result  of  the 
disorganization  of  some  of  the  surrounding  parts ;  then  they 
are  sanious. 

The  most  simple  form  of  disease  that  occurs  here,  is  in- 
flammation of  the  lining  membrane,  and  this  in  most  in- 
stances may  be  said  to  precede  all  others.  It  often  subsides 
spontaneously^  but  when  it  continues  for  a  long  time,  is  aj)t 
to  become  chronic,  and  may  then  give  rise  to  other  and 
more  formidable  kinds  of  disease.  When  unattended  by 
any  other  morbid  affection,  either  local  or  constitutional,  it 
is  easily  cured. 

A  purulent  condition  of  the  fluids  of  the  antrum  is  a 
common  affection,  but  is  seldom  met  with  in  persons  of  good 
constitutions.  It  seems  to  be  dependent  upon  a  bad  habit 
of  body  and  inflammation  of  the  pituitary  membrane  of  the 
sinus,  which  last  arises  more  frequently  from  dental  irrita- 
tion than  any  other  cause.  This  condition  of  the  secretions, 
sometimes  gives  rise  to  caries  and  exfoliation  of  portions  of 
the  surrounding  bone,  and  to  flstulous  ulcers;  but  when de- 
jiendent  upon  no  other  local  cause  than  simple  inflamma- 
tion of  the  mucous  membrane,  it  is  seldom  that  such  effects 
result  from  it.  When  complicated  with  other  morbid  con- 
ditions of  the  cavity,  they  are  not  unfrequent. 

All  purulent  conditions  of  the  secretions  of  the  pituitary 
membrane,  are  by  some  denominated  abscess.     The  name, 

*  Vide  Traite  des  Maladies  des  Fosses  Nazales  et  le  leurs  Sinus ;  p.  226. 


PRELIMINARY   REMARKS.  555 

however,  as  is  justly  remarked  by  Mr.  Tlios.  Bell,  is  im- 
proper. Abscess  is  a  different  affection,  and  seldom  occurs 
here ;  yet,  instances  of  it  have  been  met  with  at  the  ex- 
tremities of  the  roots  of  teeth  which  had  perforated  the 
sinus ;  and  it  sometimes  happens  that  when  an  abscess  is 
seated  in  the  alveolus  of  a  superior  molar,  the  matter,  in- 
stead of  making  for  itself  a  passage  through  the  socket  of 
the  tooth  on  either  side,  escapes  into  this  cavity,  and, 
finally,  with  its  secretions,  through  the  nasal  opening.  Mr. 
Bell  describes  a  case  of  abscess  seated  in  the  upper  part  of 
the  antrum  ;  but  this,  and  one  other,  are  the  only  examples 
of  the  kind  on  record. 

Ulceration  of  the  lining  membrane  is  an  affection  less 
frequently  met  with.  It  is  rarely,  if  ever,  idiopathic,  but 
seems  rather  to  be  dependent  upon  some  other  local  malady 
or  some  specific  constitutional  vice.  Scorbutic  and  scrofu- 
lous disj^ositions,  and  those  affected  with  a  venereal  taint, 
are  more  liable  to  be  affected  with  ulceration  of  this  mem- 
brane than  persons  of  sound  constitutions.  Consequently, 
it  is  seldom  cured  by  local  remedies  alone.  It  is  almost 
always  complicated  with  fungi  of  the  membrane  and  caries 
of  the  walls  of  the  sinus,  and  when  neglected,  it  sometimes 
takes  on  a  cancerous  form  and  becomes  incurable. 

The  next  form  of  disease  is  caries  of  its  walls.  This, 
though  always  complicated  with  one  or  more  forms  of  dis- 
eased action,  seems,  nevertheless,  to  be  worthy  of  separate 
consideration.  Like  ulceration  of  the  lining  membrane,  it 
is  an  effect  of  some  one  or  more  other  affections.  It  may 
result  from  accumulation  of  the  secretions  of  the  sinus,  ul- 
ceration, or  from  tumors. 

The  occurrence  of  fungous  and  other  kinds  of  tumor  is 
less  frequent  than  any  of  the  preceding  affections;  yet  this 
cavity  is  not  exempt  from  them,  and  they  constitute  the 
most  dangerous  description  of  diseases  to  which  the  superior 
maxilla  is  subject.  Although  it  is  probable,  in  their  incip- 
ient stage^  they  might  in  nearly  every  instance  be  radically 
removed,  it  is  seldom  they  are  cured  after  they  have  at- 


556  PKELIMINARY   REMARKS. 

tained  a  very  large  size,  and  implicated,  to  a  consider- 
able extent,  the  surrounding  tissues.  They  have,  however, 
been  successfully  extirpated  even  after  they  had  acquired 
great  volume,  and  implicated  to  such  an  extent  the  sur- 
rounding parts,  as  to  have  rendered  necessary  the  removal 
of  the  whole  of  the  superior  maxillary  bone.  They  usually 
grow  with  great  rapidity,  and  when  not  completely  remov- 
ed, are  soon  reproduced. 

Be.sides  these,  other  varieties  of  disease  are  occasionally 
met  with  here ;  and  the  antrum  is  liable  to  injuries,  from 
blows  and  other  kinds  of  mechanical  violence ;  from  the  in- 
troduction of  insects  and  foreign  bodies ;  but  of  these,  it  is 
not  necessa,ry  to  speak  in  this  place,  as  they  will  hereafter 
come  up  for  special  consideration. 

The  diseases  of  the  maxillary  sinus,  are  supposed  to  be 
dependent  upon  certain  specific  constitutional  vices,  the 
obliteration  of  the  opening  of  this  cavity  into  the  nose  and 
to  dental  irritation.  That  all  of  these  may,  at  times,  be 
concerned  in  their  production,  is  more  than  probable. 

But  actual  disease  rarely  develops  itself  spontaneously  as 
a  consequence  merely  of  a  bad  habit  of  bod}^  or  constitu- 
tional vice.  This  does  not  amount  to  perceptible  manifesta- 
tions of  disease  ;  but  only  occasions  an  increase  of  suscepti- 
bility of  the  tissues  to  morbid  impressions  ;  and  when  an 
imhealthy  action  is  once  induced  here,  a  more  aggravated, 
and  not  unfrequently  different  form  of  disease,  than  that 
which  would  otherwise  have  been  produced,  occurs. 

Thus  it  may  be  seen,  that  disease  of  the  maxillary  sinus 
is  dependent  upon  some  exciting  cause,  favored  by  some  con- 
stitutional vice,  for  without  this,  no  serious  morbid  efiects 
would  be  produced  ;  or  if  produced,  they  would  be  of  a  dif- 
ferent and  less  aggravated  character.  Any  disposition  or 
vice  of  body,  which  weakens  the  vital  energies  of  the  sys- 
tem^ increases  the  suscejjtibility,  or  rather  excitabilitij  of  all 
its  parts — those  of  this  cavity  equally  with  the  rest.  There 
are  various  kinds  which  have  this  efiect :  as,  for  example, 
the   scorbutic,  scrofulous,  venereal,  mercurial,  etc.,  each  of 


PRELIMHSARY   REMARKS.  55 Y 

wliicli  may  influence  the  cliaracter  of  the  morbid  action  pro- 
duced, in  a  manner  peculiar  to  itself,  or  similar  to  that 
which  might  be  exercised  by  another,  and  cause  it  to  assume 
a  greater  or  less  degree  of  malignancy,  according  as  the 
functional  operations  of  the  body  generally  are  more  or  less 
enervated  by  it. 

This  seems  to  be  the  way  in  which  a  bad  habit  of  body  is 
capable  of  afl'ecting  the  maxillary  sinus.  It  is  predisposing 
but  not  an  exciting  cause  of  disease ;  and  it  is  important 
that  this  distinction  should  be  borne  in  mind.  The  one 
should  never  be  confounded  with  the  other,  because  an  error 
of  this  sort,  might,  and  would,  in  many  instances,  lead  to 
the  adoption  of  incorrect  views  concerning  the  therapeutical 
indications  of  the  disease. 

The  writer  might  enlarge  upon  this  part  of  the  subject, 
but  it  is  not  necessary  to  do  so,  inasmuch  as  he  will  have 
occasion  to  advert  to  it  hereafter. 

Inflammation  and  ulceration  of  the  pituitary  membrane 
of  the  nose  sometimes  extend  themselves  to  the  maxillary 
sinus,  but  a  disease  is  not  so  frequently  propagated  from  the 
nasal  fossa3  to  this  cavity,  as  the  intimate  relationship  be- 
tween the  two,  might  lead  one  to  suppose.  It  is  seldom 
that  both  are  affected  at  the  same  time.  Hence  we  infer, 
that,  although  lined  by  one  common  membrane,  the  propa- 
gation of  disease  from  one  to  the  other,  is  a  rare  occurrence^ 

The  obliteration  of  the  opening  of  this  cavity  is  sometimes 
caused  by  disease  in  the  nose,  and  when  this  happens,  is 
followed  by  mucous  engorgement  of  the  sinus,  inflammation 
of  the  lining  membrane,  distension  of  the  osseous  walls, 
and  not  unfrequently  by  other  and  more  complicated  forms 
of  disease.  But  the  closing  of  this  opening  is  oftener  an 
effect  than  a  cause  of  disease  in  this  cavity,  and  it  generally 
re-establishes  itself  without  any  assistance  of  art,  after  the 
cure  of  the  affection  which  caused  it. 

If  all  the  circumstances  connected  with  the  history  of  the 
diseases  under  consideration  could  be  ascertained,  we  think 
it  would  be  found  that  these  affections  are  more  frequently 


558  PRELIMINARY  REMARKS. 

induced  by  a  morbid  condition  of  the  teetb^  gums,  and 
alveolar  processes,  than  any  other  cause.  There  are  no 
sources  of  irritation  to  which  this  cavity  is  so  much,  and  so 
often  exposed,  as  that  of  the  dental  organism.  It  is  sepa- 
rated from  the  apices  of  the  roots  of  the  superior  molars  and 
bicuspids  only  by  a  very  thin  plate  of  bone,  and  is  some- 
times even  penetrated  by  them,  so  that  it  could  scarcely  be 
otherwise,  than  that  aggravated  and  protracted  disease  in 
the  teeth  and  alveoli,  should  exert  an  unhealthy  influence 
upon  it.  The  pain  occasioned  by  diseased  teeth,  is  often 
very  severe,  sometimes  almost  excruciating,  and  inflamma- 
tion in  the  alveolo-dental  periosteum  and  gums,  frequently 
extends  itself  to  the  whole  of  one  side  of  the  face.  It  could 
hardly  be  possible,  therefore,  for  this  cavity  to  escape.  Alve- 
olar abscess,  and  sometimes  necrosis  and  exfoliation  of  the 
socket  of  the  afiected  tooth,  arise  from  the  inflammation 
thus  lighted  up.  It  often  happens,  that  the  gums  and 
alveolar  periosteum  are  affected  for  years  with  chronic  in- 
flammation, and  other  morbid  affections. 

If,  in  addition  to  these  facts,  other  proofs  be  necessary  to 
establish  the  agency  of  dental  and  alveolar  irritation  in  the 
production  of  disease  in  the  maxillary  sinus,  they  may  be 
had.  Many  of  the  affections  here  met  with,  are  often  cured 
by  the  removal  of  diseased  teeth  after  other  remedies  have 
been  employed  in  vain,  and  that,  without  even  perforating 
the  antrum.  This  would  not  be  the  case,  if  the  irritation 
did  not  arise  as  a  consequence  of  it. 

Most  writers  on  these  affections  agree  in  ascribing  them 
to  a  morbid  condition  of  the  teeth  and  alveoli.  There  are 
some,  however,  who,  though  they  admit  that  dental  irrita- 
tion may,  perhaps,  occasionally  give  rise  to  them,  seem, 
nevertheless,  to  attribute  their  occurrence,  in  the  majority 
of  instances,  to  other  causes,  such  as  irregular  exposure 
to  cold,  blows  upon  the  face,  and  certain  constitutional  dis- 
eases. 

We  shall  now  proceed  to  the  consideration  of  the  differ- 
ent affections  of  this  cavity,  under  their  respective  and  ap- 
propriate heads. 


CHAPTER    SECOND. 

IXFLAMMATIOX   OF   THE   LINING   MEMBRANE    OF    THE 
MAXILLARY  SINUS. 

Inflammation",  wlieii  not  complicated  witli  any  other  mor- 
bid aiFection,  is  the  most  simple  form  of  disease  to  which 
the  pituitary  membrane  of  the  antrum  is  subject.  As  it 
precedes  and  accompanies  all  others^  it  will  be  proper  to 
offer  a  few  remarks  upon  it,  before  entering  upon  the  con- 
sideration of  those  of  a  more  aggravated  nature. 

Inaccessible  as  it  is  here  to  most  of  the  acrid  and  irrita- 
ting agents  to  which  it  is  exposed  in  the  nasal  fossae  and 
some  other  cavities  of  the  body,  it  would  rarely  become  the 
seat  of  inflammation,  were  it  not  for  its  proximity  to  the 
teeth  and  alveolar  border,  and  simple  inflammation  rarely 
gives  rise  to  any  other  form  of  diseased  action,  unless 
favored  by  some  general  morbid  tendency  ;  and  it  usually 
subsides  spontaneously  on  the  removal  of  the  exciting  cause. 
In  good  constitutions,  it  is  less  subject  to  inflammation,  and 
consequently^  to  any  other  description  of  morbid  action, 
than  those  in  whom  there  exists  some  vice  of  body,  or  con- 
stitutional predisposition.  Febrile  and  gastric  affections, 
eruptive  diseases,  such  as  measles,  small  pox,  etc.,  syphilis, 
and  excessive  and  protracted  use  of  mercurial  medicines,  a 
scorbutic  or  scrofulous  diathesis  of  the  general  system,  and, 
in  short,  everything  that  has  a  tendency  to  enervate  the 
vital  i^owers  of  the  body,  increases  its  irritability. 

When  in  a  healthy  condition,  it  secretes  a  slightly  glu- 
tinous, transparent  and  inodorous  fluid,  by  which  it  is  con- 
stantly lubricated,  but  inflammation  changes  the  character 
of  the  secretions  ;    it  causes  them  to  become  vitiated  ;    at 


560 


SYMPTOMS   OF   INFLAMMATION. 


first,  to  be  less  abundant,  after-wards,  to  be  secreted  in 
larger  quantities  tlian  usual,  to  be  more  serous,  and  so  acrid 
as  sometimes  to  irritate  the  membrane  of  the  nose,  over 
wliich  they  pass  after  having  escaped  from  the  antrum.  It 
also  causes  them  to  exhale  an  odor  more  or  less  offensive, 
according  as  the  inflammation  is  severe  or  mild.  It  more- 
over gives  rise  to  a  thickening  of  the  membrane,  and  some- 
times to  obliteration  of  the  nasal  opening.  This  last  rarely 
occurs,  but  when  it  does  happen,  an  accumulation  of  the 
secretions  and  other  morbid  phenomena,  of  which  we  shall 
hereafter  treat,  result  from  it  as  a  necessary  consequence. 

If  at  any  time  during  the  continuance  of  the  inflamma- 
tion, the  patient  is  attacked  with  severe  constitutional  dis- 
ease, the  local  affection  will  be  aggravated,  and  sometimes 
assume  a  different  character. 

The  inflammation,  when  long  continued,  degenerates 
into  a  chronic  form^  and  is  sometimes  kept  up  for  several 
years,  without  giving  rise  to  any  other  unpleasant  effects 
than  occasional  paroxysms  of  dull  and  seemingly  deep-seated 
pain  in  the  face,  and  a  vitiated  condition  of  the  fluids  of  this 
cavity.  The  slightly  fetid  odor  which  they  exhale,  ceases 
to  be  annoying  or  even  perceptible  to  the  patient,  when  he 
becomes  accustomed  to  it. 

S  Y  M  P  T  0  M  S  . 


The  symptoms  of  inflammation  here,  though  not  always 
precisely  the  same,  are  nevertheless,  for  the  most  part,  very 
similar.  They  arc  severe,  fixed,  and  deep-seated  pain  under 
the  cheek,  extending  from  tlie  alveolar  border  to  the  lower 
l^art  of  the  orbit,  local  licat,  pulsation  and  sometimes  fever. 
Beyer  says  these  symptoms  are  not  always  present,  and  that 
inflammation  may  exist  when  it  is  not  suspected.  Other 
aflections  of  the  face  and  superior  maxillary,  may  be  mis- 
taken for  this,  and  this  for  others;  but  that  inflammation 
should  exist  without  being  attended  with  pain  or  any  other 
signs  indicative  of  its  presence,  is  scarcely  probable. 


SYMPTOMS   OF   INFLAMMATION.  561 

Deschamps  distinguishes  the  symptoms  from  those  of 
other  affections  of  this  cavity,  by  a  dull,  heavy  pain  in  the 
region  of  the  sinus,  which,  he  says,  becomes  sharp  and  lan- 
cinating, and  extends  from  the  alveolar  arch  to  the  frontal 
sinus.  The  disease  goes  on  without  interruption,  increas- 
ing until  the  superior  maxilla  of  the  affected  side  is  more  or 
less  involved.  This  malady,  he  tells  us,  cannot  be  con- 
founded with  any  other,  if  there  is  no  external  visible  cause ; 
it  differs,  he  says,  from  a  retention  of  mucus,  by  being  pain- 
ful at  the  commencement,  and  by  not  being  accompanied 
with  swelling  of  the  bones ;  he  distinguishes  it  from  polypus, 
as  that  causes  no  pain  ;  and  from  cancer,  which  occasions 
j)ain  of  a  different  kind.  ''Suppuration  and  ulcers  have 
peculiar  signs  which  cannot  be  confounded  with  those  of  in- 
flammation." Pain  in  the  molar  and  bicuspid  teeth,  ac- 
companied by  a  sense  of  fluctuation  in  the  parts,  he  seems 
to  regard  as  a  very  certain  indication  of  inflammation,  and, 
esjjecially,  when  joined  to  the  other  symptoms.  ''If  an  ex- 
ternal cause  is  discovered,  it,"  he  says,  "will  furnish  a  cer- 
tain diagnosis;"  he  also  mentions  fever  and  head-ache  as 
almost  invariable  accompaniments. 

The  inflammation,  if  not  subdued  by  ajipropriate  reme- 
dies, after  having  continued  for  a  length  of  time,  gradually 
assumes  a  chronic  form ;  the  pain  then  begins  to  diminish, 
and  is  less  constant ;  it  becomes  more  dull,  and  is  principally 
confined  to  the  region  of  the  antrum.  The  teeth  of  the 
affected  side  cease  to  ache,  or  ache  only  at  times,  but  still 
remain  sensitive  to  the  touch.  The  mucous  membrane  of 
the  nostril  next  the  diseased  sinus,  is  often  tender  and 
slightly  inflamed,  and  if  the  other  nostril  be  closed  in  the 
morning,  or  after  two  or  three  hours  sleep,  by  pressing  upon 
it  with  the  thumb  or  one  of  the  fingers,  and  a  violent  expira- 
tion be  made  through  this,  a  thin  watery  fluid,  of  a  slightly 
fetid  odor,  will  be  discharged,  and  pain  will  be  experienced 
in  the  region  of  this  cavity. 


562  TREATMENT  OF   INFLAMMATION. 


CAUSES. 


All  morbid  conditions  of  the  teetli  and  gums,  causing 
irritation  in  the  alveolar  periosteal  tissue,  may  be  regarded 
as  among  the  most  frequent  of  its  exciting  causes.  Of  the 
affections  of  the  teeth  that  do  this,  caries,  necrosis  and 
exostosis  may  be  mentioned ;  also,  loose  teeth,  and  the  roots 
of  such  as  have  been  either  fractured  in  an  attempt  at  ex- 
traction^ or  by  a  blow  or  fall,  and  left  in  their  sockets  ;  or 
that  have  remained  after  the  destruction  of  their  crowns  by 
decay.  It  sometimes  happens,  too,  that  inflammation  is 
excited  in  this  membrane  by  fractured  alveoli,  but  when  an 
accident  of  this  sort  occurs^  the  detached  portions  of  bone 
are  generally  soon  thrown  off  by  the  economy,  and  the  cause 
being  removed,  the  inflammation  immediately  subsides. 
Not  so  with  the  roots  of  teeth.  They  often  remain  con- 
cealed in  their  sockets  for  years,  unless  removed  by  art. 
Nature,  it  is  true,  makes  an  effort  to  expel  them  from  the 
jaw,  but  this  is  accomplished  only  by  a  slow  and  very  tedi- 
ous process,  and  not,  in  many  instances,  until  they  have 
given  rise  to  some  serious  affection.  But  of  the  deleterious 
effects  that  result  from  roots  of  teeth  in  the  alveoli^  it  is  not 
necessary  now  to  speak;  as  extraneous  bodies,  they  are 
always  productive  of  more  or  less  irritation.  We  might 
also  mention  exposure  to  sudden  transitions  of  temperature, 
and  certain  constitutional  diseases,  as  among  the  causes 
which  occasionally  give  rise  to  inflammation  of  this  mem- 
brane. 

TREATMENT. 

The  curative  indications  of  inflammation  of  the  lining 
membrane  of  the  antrum  are  simple,  and  for  the  most  part, 
similar  to  those  of  inflammation  in  other  parts  of  the  body. 
Bleeding  from  the  arm,  saline  purgatives,  and  fomentations 
to  the  face,  and  other  antij)hlogistic  measures  may  be  re- 
sorted to  with  advantage.    In  many  cases,  great  benefit  will 


TREATMENT   OF   INFLAMMATION.  563 

be  derived  from  the  application  of  leeches  to  the  cheek,  as 
recommended  by  Mr.  Thomas  Bell.  When  the  disease  is 
dependent,  as  in  most  instances  it  is^  upon  an  unhealthy 
condition  of  the  alveolar  processes,  the  first  thing  to  be  done 
is  to  remove  all  such  teeth,  or  roots  of  teeth,  as  are  produc- 
tive of  the  least  irritation,  for  while  any  local  sources  of 
irritation  are  permitted  to  remain,  neither  topical  nor  gen- 
eral bleeding,  or  any  other  treatment,  will  be  of  permanent 
advantage. 

Simple  inflammation  of  the  lining  membrane  of  the  an- 
trum, would  be  of  little  consequence,  were  it  not  that  it  is 
liable  to  give  rise  to  other  and  more  dangerous  forms  of  dis- 
ease, such  for  instance,  as  a  purulent  condition  of  its  secre- 
tions, or  engorgement.  It  should  never,  therefore,  be  per- 
mitted to  continue,,  but  be  as  speedily  arrested  as  possible  ; 
and  for  the  accomplishment  of  this,  the  means  here  pointed 
out,  will,  if  timely  and  properly  applied,  be  found  fully 
adequate. 


I 


CHAPTER      THIRD. 

PURULENT   CONDITION   OF   THE   SECRETIONS  AND  EN- 
GORGEMENT OF  THE  MAXILLLARY  SINUS. 

A  pmuLENT  condition  of  the  secretions  of  the  maxillary 
sinus  and  mucous  engorgement  are,  indiscriminately,  though 
very  improperly,  denominated  by  many  writers  on  the  affec- 
tions of  this  cavity,  abscess.  To  this,  neither  bears  the 
slightest  resemblance.  Deschamps  treats  of  the  former 
under  the  name  of  suppuration,  and  the  latter,  dropsy. 
Of  the  first,  he  says,  "if  after  the  time  the  inflammation 
has  passed,  the  surrounding  parts  cease  to  be  painful,  while 
the  affection  still  continues  to  cause  pain  in  the  antrum,  and 
the  fever,  though  diminished_,  occurs  at  irregular  intervals, 
and  if  the  inflammation  is  followed  by  pulsating  pain,  we 
will  have  reason  to  suppose  that  an  abscess  has  formed  in 
the  sinus  ;  and  all  doubts  will  be  removed,  if,  on  the  pa- 
tient's inclining  his  head  to  the  opposite  side,  matter  is  dis- 
charged into  tlie  nostrils,  or  if  some  tubercles  are  formed 
near  the  outer  angle  of  the  eye,  or  alveolar  border,  which 
last  happens  more  frer^uently  ;  and,  finally,  if  the  purulent 
matter,  not  finding  any  opening  through  which  to  evacuate 
itself,  distends  the  sinus  to  such  an  extent  as  to  form  a 
tumor  outwardly  upon  the  cheek."  In  short,  all  the  symp- 
toms which  he  mentions  as  belonging  to  the  disease,  are 
those  accompanying  the  one  under  consideration.  The 
matter,  he  says,  is  of  a  '^putrid  serous  consistency." 

Bordenave  has  fallen  into  a  similar  error.  He  terms  an 
altered  state  of  these  secretions,  suppuration  of  the  mem- 
brane, and  savs  that  inflammation  is  not  necessary  to  it. 


PURULENT   SECRETIONS   AND   MUCOUS  ENGORGEMENT.        565 

He  seems  to  have  confounded  in  alveolar  abscess  those  cases 
where  the  matter,  instead  of  discharging  itself,  as  it  ordi- 
narily does,  by  an  opening  which  it  makes  for  its  escape 
through  the  alveolus  and  gum  into  the  mouth,  passes  into 
the  antrum,  with  abscess  of  that  cavity.  Again,  he  asserts 
that  the  disease  (suppuration  as  he  calls  it)  may  be  inde- 
pendent of  the  surrounding  parts,  and  although  ordinarily 
implicated  with  an  altered  condition  of  them,  he  afiSrms,  it 
is  sometimes  the  effect  of  disease  primarily  seated  in  this 
cavity.* 

There  is  no  doubt  that  a  purulent  condition  of  the  fluids 
of  this  cavity  is  often  complicated  with  ulceration  of  the 
lining  membrane,  but  that  the  affection  is  at  all  analogous 
to  abscess  or  suppuration,  its  very  nature  and  situation  is 
sufficient  to  show  its  absurdity.  ''A  reference  to  the  structure 
of  the  antrum,"  says  Mr.  Bell,  ''would  appear  to  be  sufficient 
to  point  out  the  improbability,  to  say  the  least,  of  the  occur- 
rence of  abscess  in  such  a  situation.  That  a  mucous  mem- 
brane covering,  in  a  thin  layer,  the  whole  internal  surface 
of  such  a  cavity,  should  become  the  seat  of  all  the  consecu- 
tive stops  of  true  abscess,  is  a  statement  bearing  on  the  face 
of  it  an  obvious  absurdity. "f  Notwithstanding  the  seem- 
ing improbability  of  such  an  occurrence,  and  it  is  certainly 
one  that  very  rarely  happens,  abscess  does,  nevertheless, 
sometimes  develop  itself  in  this  cavity  ;  but,  it  is  a  different 
affection  altogether  from  that  usually  treated  of  under  that 
name.  We  have  already  adverted  to  a  case  narrated  by 
Mr.  B.,  a  description  of  which,  we  intend  hereafter  to  give. 

When  complicated  with  ulceration  of  the  mucous  mem- 
brane— and  it  is  probable  that  a  purulent  condition  of  its 
secretions,  in  most  instances,  is  thus  complicated — the  affec- 
tion is  precisely  analogous  to  ozena,  and,  by  many  of  the 
older  writers,  is  designated  by  that  name.  Mr.  Bell  de- 
scribes it,  and  very  properly  too,  as  being  simiLar  to  gon- 


*  Vide  Memoirs  de  I'Academie  Royale  de  Chirurg.,  vol.  12,  p.  8, 
t  Anat.  Fhys.  and  Diseases  of  the  Teeth,  p.  253. 


5G6        PrRULENT   SECRETIONS   AXD   MUCOUS   ENGORGEMENT. 

orrhea — botli  diseases  equally  consisting  of  an  altered  se- 
cretion ;  in  the  one,  of  the  pituitary  membrane,  and  in  the 
other  of  the  mucous  lining  of  the  urethra,  which,  in  neither 
instance,  possesses  any  of  the  characteristics  of  abscess, 
though  the  matter  in  both  is  purulent.* 

It  has  been  before  stated  that  the  obliteration  of  the  nasal 
opening  was  more  frequently  an  effect  than  a  cause  of  dis- 
ease in  the  maxillary  sinus  ;  it  does,  however,  sometimes 
become  closed  from  other  causes  than  an  unhealthy  condi- 
tion of  this  cavity,  and  when  this  happens,  engorgement  of 
the  sinus  is  the  inevitable  consequence.  The  fluids  thus 
accumulated  are  not  always  at  first  purulent.  They  may 
become  so,  by  retention  in  the  cavity,  and,  when  the  closing 
of  the  opening  is  the  result  of  previous  disease  in  the  an- 
trum, the  secretions  are  more  or  less  altered  from  the  very 
first. 

Accumulation  of  the  secretions  of  the  antrum,  whether 
in  a  healthy  or  purulent  state,  is  a  source  of  irritation  to  the 
lining  membrane,  and  the  pressure  which  they  ultimately 
exert  upon  the  surrounding  walls,  causes  a  new  form  of  dis- 
eased action  to  be  set  up,  which  not  unfrequently  involves 
all  the  bones  of  the  face  as  well  as  those  of  the  base  of  the 
cranium  in  disease.  When  prevented  from  escaping  through 
the  nasal  opening,  they  eventually  make  a  passage  for  their 
escape.  This  is  sometimes  effected  through  the  cheeky  at 
other  times  beneath  it,  just  above  the  alveolar  ridge,  or 
through  the  palatine  arch  or  alveoli  by  the  sides  of  the  roots 
of  one  or  more  of  the  teeth,  and  thus  establish  a  fistula, 
from  which  fetid  matter  will  be  almost  constantly  discharged. 
From  openings  of  this  sort  the  matter  is  sometimes  dis- 
charged for  years,  while  the  disease  in  the  antrum,  very  fre- 
quently, does  not  seem  to  undergo  any  apparent  change. 
At  other  times  the  membrane  ulcerates  and  the  bony  walls 
become  carious. 

A  purulent  condition  of  the  mucous  fluids  of  this  cavity, 

*  Anat.  Phvs.  and  Diseases  of  the  Teeth,  p.  254. 


PURULENT  SECRETIONS  AND   MUCOUS  ENGORGEMENT.        567 

independently  of  caries  of  tbe  bone^  or  even  of  simple  fistu- 
lous openings,  is  an  exceedingly  troublesome  and  unj)leasant 
affection.  The  odor  from  the  matter  is  often  very  annoying 
even  to  the  patient,  and  \ehen  the  secretions  are  retained  for 
some  days  in  the  sinus  before  they  escape,  the  fetor  is 
almost  insufferable. 

In  good  constitutions,  the  secretions  of  the  antrum  are  not 
so  liable  to  become  jmrulent,  though  they  be  confined  for  a 
long  time  in  the  cavity.  It  is  only  in  scrofulous,  scorbutic, 
or  debilitated  habits  that  they  are  liable  to  become  thus 
altered.  Inflammation  of  the  lining  membrane  (the  imme- 
diate or  proximate  cause)  may  exist  for  years  without  giving 
rise  to  it.  The  differences  in  the  effects  produced  upon  them 
and  the  surrounding  parts,  by  inflammation,  is  owing  to  the 
differences  in  the  state  of  the  constitutional  health  of  those 
affected  with  it. 

Where  a  jjuriform  state  of  the  secretions  is  complicated 
with  ulceration  of  the  membrane,  the  matter  will  have 
mixed  with  it  a  greater  or  less  quantity  of  flocculi,  sometimes 
of  so  firm  a  consistence,  as  to  block  up  the  nasal  openings 
and  prevent  its  exit.  Mr.  Thomas  Bell  says,  he  has  seen 
more  than  one  case  in  which  a  considerable  acccumulation 
had  taken  place  in  the  antrum,  accompanied  by  the  usual 
indications  of  this  affection,  (muco-purulent  engorgement  of 
the  sinus,)  when  a  sudden  discharge  of  the  contents  into 
the  nose  took  place,  '"'in  consequence  of  the  j)ressure  having 
overcome  the  resistance  which  had  thus  been  offered  to  its 
escape."*  Cases  of  a  very  similar  nature  have  fallen  under 
our  observation,  the  history  of  one  of  which  will  be  given 
in  the  course  of  this  chaj^ter.  The  formation  of  these 
flocculi  rarely  cease,  excejit  with  the  cure  of  the  ulcers  of 
the  membrane.  They  give  rise  to  considerable  irritation, 
and  their  presence  always  constitutes  an  obstacle  to  the 
cure.     They  are  usually  easily  removed  by  injections. 

The  pituitary  membrane  of  the  antrum  when  in  a  healthy 
state,   secretes,  as  we  have   before   stated,   a  transj)arent, 

*  Vide  Anat.  Pbys.  and  Diseases  of  the  Teeth,  p.  258. 


568  SYMPTOMS  OF  PURULENT   SECRETIONS,  &C. 

sligjitly  glutinous  and  inodorous  fluid,  poured  out  only  in- 
sufficient quantity  to  lubricate  the  cavity.  But  when  in- 
mation  is  excited  in  the  membrane,  its  secretions  soon 
become  more  abundant,  and,  at  first  thinner,  afterwards 
thicker  and  more  glutinous.*  Their  color  and  consistence 
are  not  always  the  same.  Instead  of  being  transparent, 
they  sometimes  have  a  dirty  opaque  appearance  ;  at  other 
times  they  assume  a  greenish,  whitish  or  yellowish  color, 
and  in  some  instances  they  bear  a  considerable  resemblance 
to  pus,  which  has  been  conjectured^  might  be  owing  to  sup- 
puration of  some  of  the  mucous  follicles  and  a  mixture  of 
pus  with  its  secretions.  Mr.  Thomas  Bell,  however,  inclines 
to  the  opinion  that  it  is  attributable  to  an  ''alteration 
simply"  of  the  secretions  of  the  cavity.  But  their  color 
and  consistence  are  determined  by  the  degree  of  inflamma- 
tion, the  length  of  time  it  has  existed,  the  state  of  the 
health  of  the  lining  membrane,  and  that  of  the  surround- 
ing osseous  walls,  the  egress  which  the  matter  has  from  the 
sinus  and  the  general  habit  of  the  body. 

Afiections  of  this  sort,  are  more  common  to  young  sub- 
jects than  to  middle  aged,  or  persons  in  advanced  life.  An 
eminent  French  writer  says,  that  of  three  individuals  af- 
fected with  dropsy  (mucous  engorgement)  the  oldest  was 
not  twenty  years  of  age.f 

SYMPTOMS. 

The  diagnoses  of  the  several  affections  of  the  antrum  are 
so  much  alike,  that  it  is  often  difficult  to  distinguish  those 
that  belong  to  one  from  those  attendant  upon  another.  The 
symptoms  of  mucous  engorgement  and  purulent  accumula- 
tions, however,  are  generally  such,  as  will  enable  the  prac- 
titioner to  distinguish,  with  considerable  certainty,  these 
from  other  affections.     They  are  always  preceded  by  inflam- 

*  Vide  JIaladies  Chirurgicale,  torn,  ri,  p.  140. 

t  Vide  Traite  des  Maladies  Chirurgicales  et  de8  Operations  qui  leur  conviennent, 
torn,  vi,  p.  139. 


SYMPTOMS   OF   PURULENT  SECRETIONS,  &C.  569 

mation  of  the  lining  membrane ;  a  description  of  tlie  symp- 
toms of  wliicli,  having  already  been  given,  need  not  be  re- 
peated. Omitting  these,  we  at  once  j)roceed  to  mention 
those  by  which  they  are  accompanied. 

In  speaking  of  the  symptoms  more  particularly  belonging 
to  a  purulent  condition  of  the  secretions  of  the  antrum, 
Deschamps  says,  the  affection  may  be  distinguished  by  dull 
heavy  pain,  extending  along  the  alveolar  border.  Upon, 
this  symptom  alone,  little  reliance  can  be  placed,  as  it  is 
always  present  in  chronic  inflammation.  In  addition  to 
this,  he  mentions  the  presence  of  decayed  teeth,  soreness  in 
those  that  are  sound,  and  on  the  patient's  inclining  his  head 
to  the  side  opposite  the  one  affected,  the  discharge  of  fetid 
matter  from  the  nose.  These  are  very  conclusive  indica- 
tions of  purulent  effusions  in  this  cavity.  Bordenave,  after 
enumerating  the  symptoms  indicative  of  inflammation,  men- 
tions the  following  as  belonging  to  the  affection  of  which  we 
are  now  speaking,  viz.  dull  and  constant  pain  in  the  sinus^ 
extending  from  the  maxillary  fossee  to  the  orbit ;  a  discharge 
of  fetid  matter  from  the  nose,  when  the  patient  inclines  his 
head  to  the  opposite  side,  or  when  the  nose  is  blown  from 
the  nostril  of  the  affected  side.*  These  symptoms  are  men- 
tioned by  almost  every  writer  upon  the  subject,  as  indicative 
of  a  purulent  condition  of  the  secretions  of  the  maxillary 
sinus. 

The  symptoms  of  engorgement  differ  materially  from 
those  which  denote  simply  a  purulent  condition  of  the  mu- 
cous secretions.  The  pain,  instead  of  being  dull  and  heavy^ 
as  just  described,  becomes  acute^  and  a  distressing  sense  of 
fullness  and  weight  is  felt  in  the  cheek,  accompanied  by 
redness  and  tumefaction  of  the  integuments  covering  the 
antrum. t  The  nasal  opening  having  become  closed,  the 
fluids  of  the  cavity  gradually  accumulate  until  they  fill  it, 
when,  finding  no  egress,  they  press  upon  and  distend  the 
surrounding  osseous  walls,  causing  those  parts  which  are 

*  Vide  Memoirs  de  I'Academie  Royale  de  Chirurgie,  12mo,  torn.  12,  p.  10. 
t  Tide  Bell  on  the  Teeth,  p.  266,  see  also  Maladies  des  Fosses  Nazales,  p.  228. 

37 


570  CAUSES   OF   PURULENT  SECRETIONS,    &C. 

the  thinnest  ultimately  to  give  way.  The  effects  are  gene- 
rally first  observable  anteriorly  beneath  the  malar  eminence, 
where  a  smooth  hard  tumor  presents  itself,  covered  with  the 
mucous  membrane  of  the  mouth.  But  this  is  not  always 
the  point  which  first  gives  away,  the  sinus  sometimes  bursts 
into  the  orbit,  at  other  times  outwardly  through  the  cheek, 
or  through  the  palatine  arch.  The  long  continued  pressure 
thus  exerted  upon  the  bony  walls,  often  causes  the  destruc- 
tion of  their  calcareous  molecules,  and  softening  of  their 
tissues. 

The  tumor,  which  is  at  first  hard,  in  a  short  time  becomes 
so  soft  as  readily  to  yield  to  pressure.  A  distention,  Des- 
champs  says,  may  be  distinguished  from  other  diseases  that 
affect  the  skin  or  intermediate  structure  between  it  and  the 
bone,  by  the  uniformity  or  regularity  of  the  tumor,  its 
firmness  at  the  commencement^  the  slowness  with  which  it 
progresses,  and,  above  all,  by  the  natural  appearance  of 
the  skin,  and  the  absence  of  pain  when  pressure  is  made 
upon  the  tumor.  Obliteration  of  tlie  nasal  opening,  he 
says^  may  be  suspected  by  the  dryness  of  the  nostril  of  the 
affected  side,  the  mucous  membrane  of  which  becomes 
thickened,  and  the  cavity  contracted ;  inflammation  and 
sponginess  of  the  gums,  loosening  and  sometimes,  (inconse- 
quence of  the  destructoin  of  their  sockets^)  displacement  of 
the  teeth,  may  also  be  mentioned  as  occasional  accompani- 
ments of  engorgement. 

CAUSES. 

Inflammation  of  the  mucous  membrane,  is  the  cause  of  a 
purulent  condition  of  the  secretions  of  the  maxillary  sinus, 
and  this  arises  more  frequently  from  alveolo-dental  irrita- 
tion than  from  any  particular  habit  of  body  or  constitutional 
disturbance.  Engorgement  results  from  the  obliteration  of 
the  nasal  opening,  which,  in  the  case  of  altered  secretion, 
is  usually  caused  by  inflammation  and  thickening  of  the 
lining  membrane. 


TREATMENT   OF   PURULENT    SECRETIONS,    &G.  571 

TREATMENT. 

The  curative  indications  of  muco-purulent  secretion  and 
engorgement  of  the  maxillary  sinus  are,  1st,  if  the  nasal 
opening  be  closed,  the  evacuation  of  the  retained  matter ; 
2dly,  the  removal  of  all  local  and  exciting  causes  of 
irritation ;  3dly,  and  lastly,  the  restoration  of  the  lining 
membrane. 

For  the  fulfilment  of  the  first,  an  opening  must  be  made 
into  the  antrum,  and  this  should  be  effected  in  that  part 
which  will  afford  the  most  easy  exit  to  the  retained  matter ; 
but  as  it  regards  the  several  methods  that  have  been  pro- 
posed for  the  accomplishment  of  this  object,  practitioners 
differ ;  and  before  we  proceed  further,  it  may  not  be  amiss 
to  notice  some  of  the  various  methods  that  have  been 
adopted. 

Dr.  Drake,  an  English  anatomist,  and  author  of  a  work 
entitled  "Aiith'opologia  Nova,"  has  the  credit  of  being  the 
first  to  propose  the  perforation  of  the  floor  of  the  sinus, 
through  the  alveolus  of  one  of  the  roots  of  a  molar  tooth. 
Tliis  method  of  procedure,  however,  is  said  by  some  to  have 
been  inserted  into  Drake's  Anatomy  by  Dr.  Cowper,  an 
eminent  anatomist  and  surgeon.*  Having  never  seen  any 
evidence  touching  the  correctness  of  this  conjecture,  we  sup- 
pose its  truth  is,  probably,  somewhat  questionable.  M. 
Gunz  says,  the  credit  belongs  to  John  Henry  Meibomius, 
who,  a  long  time  before,  proposed  a  very  similar  method  of 
treating  these  affections. f  Henry  Meibomius,  many  years 
after  the  death  of  liis  father,  John  Henry,  proposed,  for  the 
evacuation  of  accumulated  fluids  in  the  antrum,  the  extrac- 
tion of  one  of  several  teeth.  J  But  the  jierforation  of  the 
maxillary  sinus  through  the  alveolus  of  a  molar  tooth,  is 
said  not  to  be  the  most  ancient  method.  Molinetti,  as  early 
as  the  year   1675,  describes  an  opening  made  through  the 

*  Heistei's  Surgery,  note  to  chapter  72,  p.  445. 
t  Vide  Mem.  de  I'Acad.  Royale  de  Chirurg.  12mo,  vol.  xii,  p.  12. 
i  Vide  Discurs.  de  Abscessibus  Internis.  Dresd.,  1718,  p.  114,  and  la  Disserta- 
tion d'Gunz. 


572  TREATMENT   OF   PURULENT  SECRETIONS,    <feC. 

cheek  into  the  antrum,  the  wall  of  which,  after  having  been 
exposed  by  a  crucial  incision  through  the  integuments 
covering  it,  was  penetrated  with  a  trephine.  And  tlie  per- 
foration of  this  cavity  through  the  alveolus  of  a  superior 
molar,  is  an  operation  which,  according  to  Velj)eaU;,  was 
performed  by  Zwinger,  a  long  time  before  it  was  made  by 
Meibomius ;  and  Yanuessen  says,  Kuysch  extracted  several 
molars  and  cauterized  their  sockets,  for  the  destruction  of  a 
polypus,  until  an  opening  was  made  into  the  antrum,  large 
enough  to  admit  the  finger.  Drake,  according  to  Borde- 
nave,  seems,  neverthless,  to  be  entitled  to  the  credit  of  hav- 
ing been  the  first  to  perforate  the  maxillary  sinus  as  above 
described.  We  are  also  informed  by  the  same  author  that 
Cowper  treated  a  case  of  maxillary  ozena,  which  had  caused 
a  large  quantity  of  ichorous,  fetid  matter,  to  be  discharged 
through  the  nose,  by  extracting  the  first  molar,  and  per- 
forating the  antrum  through  the  alveolus  with  an  instru- 
ment suited  to  the  purpose. 

It  is  not  at  all  probable  that  Meibomius  was  the  first  to 
propose  the  perforation  of  the  antrum  in  this  way,  for  his 
researches  were  not  juiblished  until  1718,  twenty-one  years 
after  the  publication  of  Drake's  System  of  Anatomy,  and, 
besides,  he  regarded  the  perforation  of  this  cavity  as  a  dan- 
gerous operation,  and,  on  that  account,  confined  himself 
simply  to  the  extraction  of  a  tooth.  Saint  Yves,  says  Yel- 
peau,  treated  with  success  a  person  afiected  with  fistula,  the 
floor  of  whose  orbit  had  been  destroyed  by  the  removal  of  a 
tooth. 

With  regard  to  the  tooth  most  proj^er  to  be  extracted,  au- 
thors differ.  Cheseldon  preferred  the  first  or  second  molar, 
Junker  recommends  the  extraction  of  the  first  or  second 
bicuspid,  and  if  a  fistula  had  formed,  to  enlarge  it  instead 
of  perforating  the  floor  of  the  antrum.  But  the  second 
molar,  it  being  directly  beneath  the  most  dependent  part  of 
the  cavity,  is  the  most  suitable  tooth  to  be  removed.  If  this 
be  sound,  the  first  molar,  dens  sapientiae,  or  either  of  the 
bicuspids,,  if  carious,  may  be  extracted   in   its   stead,   and 


TREATMENT   OF   PURULENT   SECRETIONS,    A-C.  573 

in  fact,  no  tooth  beneatli  the  antrum,  in  an  unhealthy  con- 
dition, shoukl  he  permitted  to  remain. 

An  opening  having  been  eiFected  through  the  alveolus  of 
a  tooth,  into  the  antrum,  it  should  be  kept  open  until  the 
health  of  the  cavity  is  restored.  For  this  purpose,  sounds 
and  bougies  adapted  to  the  purpose  have  been  introduced. 
Heuerraan  recommends  the  employment  of  a  small  canula, 
which  is  also  preferred  by  Bordenave  and  Ritchter,  the  lat- 
ter of  wliom  says,  it  should  be  kept  closed  to  prevent  par- 
ticles of  food  from  getting  into  the  sinus.  But  whether  a 
canula  or  bougie  be  introduced  into  the  opening,  it  should 
be  so  secured  as  to  prevent  it  from  coming  out  or  passing 
into  the  antrum.  Deschamps  recommends  that  it  be  fas- 
tened to  one  of  the  adjoining  teeth  by  means  of  a  silk  or 
metallic  ligature. 

Lamorier,  an  eminent  surgeon  of  Montpellier,  recom- 
mended perforating  the  antrum  immediately  above  the  first 
molar,  or  rather  between  it  and  the  malar  bone.  In  this, 
he  seems  to  have  been  influenced  by  the  consideration  that 
the  wall  of  the  cavity  here,  presents  the  least  thickness,  and 
that  tliis  is  the  most  dependent  part  of  the  sinus.  If  a  fis- 
tulous opening  had  previously  formed  in  some  other  place 
in  the  mouth,  he  did  not  always  deem  it  necessary  to 
make  another.  His  method  of  operating  is  as  follows : 
The  jaws  being  closed,  the  commissure  of  the  lips  are  drawn 
outwards  and  slightly  upwards  with  a  curved  instrument, 
called  a  speculum  ;  this  done,  the  gum  is  incised  across  the 
malar  apophysis,  or  maxillo-labial  sulcus,  and  the  bone 
made  bare,  which  is  next  pierced  with  a  spear-pointed 
punch.  The  opening  is  afterwards  enlarged  if  found 
necessary. 

Desault  is  of  the  opinion  that  the  opening  should  be  made 
through  the  canine  fossa,  beneath  the  upper  lip,  and  for 
that  purpose,  after  having  laid  bare  the  bone,  he  emi)loy- 
ed  a  sharp  triangular  and  a  blunt  pointed  perforator,  which 
he  invented  for  the  operation.  Runge,  says  Velpeau_,  used 
nothing  but  a  scalpel.     Mr.  Charles  Bell  invented  a  tre- 


5V4  TREATxMENT    OP   PURULENT   SECRETIONS,  &C. 

phine  for  that  purpose,,  but  this  does  not  possess  any  ad- 
vantage over  the  instruments  employed  be  Desault  and 
Runge.  In  case  of  fistula  in  the  cheek  from  the  antrum, 
RufFel  advises  the  insertion  of  a  trocar,  to  be  carried  through 
the  gum,  so  as  to  form  a  counter  opening.  Through  this, 
in  a  case  which  he  treated,  he  passed  a  seton,  and  it  remain- 
ed six  weeks  ;  at  the  expiration  of  this  time,  a  cure  was  ac- 
complished. This  practice  has  been  followed  by  Callisen, 
Zang,  Busch,  Henkle,  Bertrandi,  Faubert  and  others.  Cal- 
lisen is  of  the  opinion  that  when  the  tumor  points  in  the 
palatine  arch  and  fluctuation  is  felt,  the  artificial  opening 
should  be  formed  there.  Gooch,  in  a  case  which  he  treated, 
advised  the  perforation  of  the  antrum  through  the  nasal 
surfixco,  and  fixing  in  the  opening  a  canula  of  lead.  We 
are  also  informed  by  the  same  author,  that  Acrel,  after 
having  operated  in  the  manner  proposed  by  Cowper,  insert- 
ed a  second  canula  into  the  sinus  through  a  fistulous  open- 
ing formed  in  the  nose.  The  method  attributed  to  Wein- 
hold,  consists  in  penetrating  the  sinus  from  the  upper  and 
external  part  of  the  canine  fossa^  with  the  instrument  di- 
rected obliquely  downwards  and  outwards,  so  as  to  avoid 
the  branches  of  the  infra-orbital  nerve  ;  and  then  placing  in 
the  opening  thus  made  a  little  lint.  Weinhold  directs, 
that  when  the  antrum  has  no  other  opening,  the  instrument 
should  be  carried  entirely  through  the  palatine  arch,  and 
then  by  means  of  a  curved  needle  and  thread,  he  intro- 
duces a  roll  of  lint,  saturated  or  covered  with  some  appro- 
priate medicine,  and  this,  he  designs  to  act  as  a  seton. 

Velpeau  says,  the  perforation  is  affected  "in  the  point  of 
election  or  of  necessity.  The  first  varies  according  to  the 
ideas  of  the  operator.  The  circumstances,  on  the  contrary^ 
determine  the  second.  In  cases  of  abscess,  dropsy,  fistula, 
iiiid  ulceration,  the  operation  is  almost  always  performed  in 
the  place  of  election.  Then,  provided  one  of  the  molar 
teeth  to  be  unsound,  it  must  be  extracted,  together  with  the 
adjoining  tooth  ;  the  gum  is  then  to  be  cut  down  to  the 
bone,  externally,  internally,  behind  and  before,    forming  a 


TREATMENT   OF   PURULENT   SECRETIONS,    &C.  575 

kind  of  square  flap,  and  to  be  completely  detached  from  the 
surrounding  tissues  ;  after  this  the  alveolus  are  to  be  perfo- 
rated with  the  instruments  of  Desault,  and  an  opening  made 
large  enough  to  admit  the  finger  into  the  sinus."  For  the 
evacuation  simply  of  purulent  mucus,  or  accumulated  fluids, 
we  believe  with  Boyer,  that  the  opening  should  always  be 
made  from  beneath  ;  and  we  are  the  more  convinced  of  the 
importance  of  giving  the  alveolus  of  an  extracted  tooth  the 
preference,  from  the  consideration  that  it  is  to  the  irritation 
produced  by  some  one  or  more  of  these  organs,  that  the  dis- 
eases of  this  cavity  are  attributable.  Even  though  a  fistu- 
la may  have  formed  above  the  alveolar  ridge,  beneath  the 
cheek,  or  in  the  palatine  arch,  we  should  not  neglect  to  ex- 
tract such  teeth,  whether  carious  or  sound,  as  may  be  pro- 
ductive of  irritation.  It  may  not  always  in  such  cases  be 
necessary  to  perforate  the  sinus  from  the  socket  of  a  tooth, 
though  the  cure  in  most  instances,  is  expedited  by  it. 

Jourdain,  an  eminent  French  dentist,  and  graduate  in 
surgery,  instead  of  seeking  egress  for  matter  accumulated  in 
the  maxillary  sinus,  by  any  of  these  methods^  proposed,  in 
a  memoir  presented  to  the  Academy  in  1765,  to  probe  the 
cavity  by  its  natural  opening,  and  then  by  suitable  injec- 
tions to  restore  it  to  health.  The  Academy  gave  this  pro- 
position its  attention  ;  it  was  carefully  and  minutely  dis- 
cussed. Tlie  practicability  of  obtaining  entrance  into  the 
sinus  in  this  way  was  called  in  question  ;  it  was  contended 
that  the  difficulties  presented  by  the  peculiar  structure  of  the 
parts  were  such  that  they  would  seldom  be  overcome.  The 
practice  has  been  wholly  abandoned. 

When  the  natural  opening  is  closed,  the  first  indication, 
as  has  been  stated,  is  the  evacuation  of  the  matter,  and  for 
this  purpose,  a  j)erforation  should  be  made  into  the  sinus, 
and  the  most  proper  place  for  effecting  this,  it  has  been 
shown,  is  through  the  alveolar  cavity  of  the  second  molar.* 
It  may,  however,  be  penetrated  from  that  of  either  of  the 
other  molars  or  bicuspids. 

*  Vide  Anat.  I'hys.  and  Diseases  of  the  Teeth,  p.  261. 


576  TREATMENT   OF   PURULENT  SECRETIONS,  &C. 

The  perforations,  after  the  extraction  of  the  tooth,  is 
made  with  a  straight  trochar,  which  will  he  found  more 
convenient  than  those  usually  employed  for  the  purpose. 
The  point  of  the  instrument,  after  having  been  introduced 
into  the  alveolus,  through  which  it  is  intended  to  make  the 
opening,  should  he  pressed  against  the  bottom  of  the  cavity 
in  the  direction  towards  the  centre  of  the  antrum.  With 
the  handle  of  the  instrument  in  the  hand  of  the  operator,  a 
few  rotary  motions  will  suffice  to  pierce  the  intervening 
plate  of  hone.*  If  the  first  opening  be  not  sufficiently  large, 
its  dimensions  may  be  increased  to  the  necessary  size,  by 
means  of  a  spear-pointed  instrument.  In  introducing  the 
trochar,  cave  should  be  taken  to  prevent  a  too  sudden  en- 
trance of  the  instrument  into  the  cavity.  AVithout  this  pre- 
caution, it  might  be  suddenly  forced  against  the  opposite 
wall.  The  euirauco  is  usually  attended  with  a  momentary 
severe  pain,  and  the  withdrawal  of  the  instrument  followed 
by  a  sudden  gush  of  fetid  mucus. 

It-  is  not  always  necessary  to  perforate  the  floor  of  the 
antrum  after  the  extraction  of  the  tooth  ;  it  occasionally 
happens,  as  has  already  been  remarked,  that  some  of  the 
alveolar  cavities  communicate  with  it. 

An  opening  having  thus  been  effected,  it  should  be  pre- 
vented from  closing,  until  a  healthy  action  is  established  in 
the  lining  membrane,  and  for  this  purpose,  a  bougie,  or 
leaden  or  silver  canula,  may  be  inserted  into  the  opening 
and  secured  to  one  of  the  adjacent  teeth.  It  should,  how- 
ever, be  removed  for  the  evacuation  of  the  secretions,  at 
least  twice  a  day.  The  formation  of  an  opening  at  the 
base  or  most  dependent  part  of  the  sinus,  will,  in  those 
cases  where  a  fistula  has  been  previously  formed,  in  most 
instances,  be  followed  by  its  speedy  restoration.  Having 
proceeded  thus  far,  the  cure  will  be  aided  by  the  employ- 
ment of  such  general  remedies  as  may  be  indicated  by  the 

*  In  a  collection  of  nearly  one  hundred  jaws,  presented  to  the  Museum  of  the 
Baltimore  Dental  College,  by  Dr.  Maynard,  the  floor  of  the  antrum  varies  in  thick- 
ness, from  that  of  tissue  paper,  to  half  an  inch. 


TREATMENT   ilF   PURULENT   SECRETIONS,  <feC.  57*7 

state  of  the  constitutional  health,  and  for  the  dispersion  of 
the  local  inflammation,  leeches  to  the  gums  and  cheek  will 
be  found  serviceable.  The  antrum  may,  in  the  meantime, 
be  injected  with,  at  first,  some  mild  or  bland  fluid,  and 
afterwards  with  gently  stimulating  liquids.  Diluted  port 
wine,  a  weak  solution  of  the  sulphate  of  zinc  and  rose  water, 
and  also  that  of  copper  and  rose  water,  have  been  recom- 
mended. Diluted  tinct.  of  myrrh^  may  sometimes  be  ad- 
vantageously employed,  and  when  the  membrane  is  ulcera- 
ted, a  solution  of  nitrate  of  silver,  will  be  highly  service- 
able. The  author  has  used  a  solution  of  iodide  of  potassium 
with  advantage  ;  also,  a  weak  alcoholic  solution  of  tannic 
acid.  For  correcting  the  fetor  of  the  secretions,  a  weak 
solution  of  the  chloride  of  soda  or  lime,  may  be  occasionally 
injected  into  the  antrum. 

In  cases  of  muco-purulent  secretions  simply,  a  weak 
decoction  of  galls  may  be  injected  into  the  sinus  with  ad- 
vantage. 

Injections  of  a  too  stimulating  nature  are  sometimes  em- 
ployed. This  should  be  carefully  guarded  against,  by 
making  them  at  firs'  weak,  and  afterwards  increasing  their 
strength  as  occasion  may  require ;  but  if  symptoms  of  a  vio- 
lent character  are  l)y  this  means  produced,  they  should  be 
combated  by  applying  leeches  to  the  gums  and  fomentations 
to  the  cheek. 

Dependent  as  these  affections  in  most  instances  are,  upon 
local  irritants,  greater  reliance  is  to  be  placed  on  their  re- 
moval and  giving  vent  to  the  acrid  puriform  fluids,  than  to 
any  therapeutical  effects  exerted  upon  the  cavity  by  injec- 
tions. As  adjuvants,  they  are  serviceable,  but  a  cure  can- 
not be  effected  while  the  exciting  cause  remains  unreraoved. 

The  following  cases  may  serve  to  illustrate  the  treatment 
usually  pursued  in  cases  of  this  kind. 

Case  1st.  Mrs.  T.,  a  married  lady,  of  about  forty-five  years 
of  age,  of  a  bilious  temperament,  applied  to  the  author  for 
advice,  in  1853.  She  had  suffered  from  neuralgic  pains  in 
her  face  and  temples,  at  times,  for  nearly  twenty  years,  and 


578  TREATMENT   OF   PURULENT  SECRETIONS,  &C. 

as  all  of  her  teeth,  especially  of  the  upper  jaw,  were  so  much 
decayed  as  to  preclude  the  possibility  of  restoration,  he  urged 
their  immediate  removal.  She  submitted  to  the  operation, 
hoping  it  would  relieve  her  from  the  pain,  to  which,  to  use 
her  own  words,  she  had  "so  long  been  a  martyr,"  intend- 
ing to  have  the  lost  organs  replaced  with  an  artificial  set. 
She  called  again  in  a  few  months,  partly  for  this  purpose 
and  partly  to  obtain  relief  from  pain  which  she  still  experi- 
enced. But  now  it  was  not  so  much  diflused  as  formerly. 
It  was  almost  wholly  confined  to  the  left  side  of  the  face. 
On  inquiry,  it  was  ascertained  that  fetid  matter  was  occa- 
sionally discharged  from  the  nostril  of  the  affected  side. 
This  led  him  to  suspect  that  the  antrum  was  diseased.  An 
opening  was  accordingly  made  through  the  alveolar  border, 
at  the  point  originally  occupied  by  the  second  molar.  The 
withdrawal  of  the  instrument  was  followed  by  the  discharge 
of  a  small  quantity  of  purulent  matter.  The  antrum  was 
now  forcibly  injected  with  water.  This  caused  the  dis- 
charge of  more  than  two  table-spoonfuls  of  hardened  flocculi 
from  the  left  nostril,  which  from  long  confinement,  was  in- 
suffei'ably  offensive.  The  injection  was  repeated  until  the 
antrum  was  completely  freed  from  this  accumulation.  A 
solution  of  sulphate  of  zinc,  in  the  proportion  of  six  grains 
to  the  ounce  of  water,  was  now  substituted.  The  sinus  was 
injected  daily  with  this  for  a  little  more  than  a  week,  and 
without  any  other  treatment  a  complete  cure  was  effected. 

The  paiticulars  of  the  following  case  are  obtained  from 
"Observations  of  Bordenave  on  the  Diseases  of  the  Maxil- 
lary Sinus,"*  a  paper  embodying  reports  of  forty  highly  in- 
teresting cases. 

Case  2d.  ''In  1756,"  says  our  author,  "I  was  consulted 
by  a  lady  whose  right  cheek  was  tumefied.  About  a  month 
previous  she  had  experienced  acute  pain  under  the  orbit  of 
the  affected  side  ;  and  she  had  felt  a  pulsation  and  heat  in 
the  interior  of  the  sinus,  and  the  maxillary  bone  was  slightly 

*  Mem.  de  I'Acad.  Rojale  de  Chirurg.,  vol.  xii,  obs.  3,  p.  10. 


TREATMENT   OF   PURULENT   SECRETIONS,  &C.  5*79 

elevated.  These  signs  determined  me  to  propose  the  extrac- 
tion of  the  third  molar  tooth,*  and  the  perforation  of  the 
antrum  through  the  alveolus.  The  operation  was  followed 
by  a  discharge  of  purulent  matter,  the  sinus  was  afterwards 
injected,  the  maxilla  gradually  reduced  itself,  and  a  cure  was 
effected  in  about  two  months." 

Although  injections  were  employed  in  the  above  case,  it 
was  no  doubt,  the  giving  vent  to  the  matter  contained  in  the 
antrum  that  the  cure  was  attributable.  As  it  regards  the 
cause  that  gave  rise  to  the  affection  in  the  first  instance,  not 
a  single  word  is  said.  It  may  have  resulted  from  inflam- 
mation, lighted  up  in  the  sockets  of  one  or  more  teeth,  and 
propagated  from  thence  to  the  mucous  membrane  of  this 
cavity,  or  from  inflammation  produced  by  some  other  cause, 
and  consequent  obliteration  of  the  nasal  opening. 

The  following  brief  statement  is  taken  from  the  history  of 
a  case  narrated  by  Fauchard.f 

Case  od.  The  child  of  M.  G-alois,  a^t.  twelve  years,  whose 
first  right  superior  molar  was  decayed,  had  a  tumor  situated 
anteriorly  upon  the  upper  jaw  of  the  same  side,  extending 
up  to  tlie  orbit.  M.  Fauchard,  supposing  this  tumor,  which 
was  about  the  size  of  a  small  egg,  had  been  caused  by  the 
carious  tooth  in  question,  determined  on  its  extraction  as  the 
only  means  of  effecting  a  speedy  and  certain  cure,  and  the 
result  proved  his  opinion  correct.  The  removal  of  the  tooth 
was  followed  by  a  large  quantity  of  yellow  serous  matter, 
which,  on  examination,  was  found  to  have  escaped  from  the 
antrum.  The  tumor  disappeared  soon  after  the  discharge 
of  the  matter,  and  a  complete  cure  was  effected. 

Bordenave,  in  noticing  the  foregoing  case,  does  not  believe 
that  the  tumor  communicated  with  the  maxillary  sinus,  for 
the  reason  that  the  matter  escaped  through  the  alveolus  of 
the  first  molar  immediately  after  its  extraction.  He,  how- 
ever, admits  that  the  acumen  and  knowledge  of  Fauchard, 

*  The  bicuspids  are  called  bj  most  French  writes,  molars,  and   by  the  "third 
molar  tooth,"  he  means  the  one  which  we  call  the  first. 
t  Le  Chirurgien  Dentiste,  tom.  i,  obs.  8,  p.  483. 


580  TREATMENT   OF   PURULENT   SECRETIONS,  &C. 

are  siicli  as  to  have  prevented  deception  in  the  case.  Ad- 
mitting, then,  the  statement  to  be  correct,  and  snrely  the 
circumstance  mentioned  by  Bordenave  does  not  in  the  least 
tend  to  invalidate  it,  for  it  is  of  frequent  occurrence,  a  cure 
is  eflfected  simply  by  the  removal  of  a  decayed  tooth,  to  the 
Irritation  produced  by  which  the  disease  was  undeniably  at- 
tributable. The  two  following  cases  are  described  at  length 
by  the  last  named  author  in  the  "Memoirs  de  1' Academic 
Eoyale  de  Chirurgie."* 

Case  4th,  A  woman,  in  1731,  had  the  first  superior 
molar,  the  crown  of  which  had  been  destroyed  by  caries,  ex- 
tracted. Not  many  days  after  the  operation,  she  was  at- 
tacked with  pain  in  the  upper  jaw,  which  extended  from 
the  maxillary  fossa  to  the  orbit.  The  pain  was  so  great  as 
to  deprive  her  of  rest,  but  there  was  no  tumefaction  of  the 
cheek  or  gums.  An  opening  through  the  alveolus  into  the 
sinus  was  discovered,  into  which  a  probe  was  introduced  by 
a  surgeon.  The  withdrawal  of  this  was  followed  by  a  dis- 
charge of  yellow  fetid  matter.  M.  Lamourier,  who  was  after- 
wards consulted,  removed  from  the  opening  a  tooth  that  had 
been  thrust  into  the  antrum  and  prevented  the  egress  of  the 
matter,  which,  by  its  retention,  had  become  purulent.  In- 
jections were  employed,  a  part  of  which,  at  the  expiration 
of  thirty  days,  escaped  from  the  nasal  opening.  A  perfect 
cure  was  soon  after  effected. 

In  this  case,  the  affection  of  the  sinus,  was  evidently  the 
result  of  the  injury  inflicted  upon  the  socket  of  the  first  su- 
perior molar,  in  an  attempt  at  the  extraction  of  the  tooth. 
Inflammation  was  excited  by  this  and  the  presence  of  the 
tootli  that  had  been  thrust  into  the  antrum,  which  extended 
itself  to  the  lining  membrane  of  this  cavity,  and  caused  a 
temporary  obliteration  of  the  nasal  opening,  so  that  to  effect 
a  cure  it  was  necessary  to  obtain  free  vent  for  the  retained 
matter.     In  restoring  a  healthy  action  to  the  mucous  mem- 

*  Vide  vol.  xii,  12mo,  Observations  5  and  6,  pp.  12  and  19. 


TREATMENT   OF   PURULENT   SECRETIONS,  &C.  581 

brane  of  the   cavity,   the   injections  may  have   been   ser- 
viceable. 

Case  5th.  A  girl,  aet.  twenty-six  years,  in  having  a  de- 
cayed and  painful  superior  dens  sapientite  on  the  right  side 
extracted,  the  tooth  was  broken  and  all  the  roots  but  one 
were  left  in  their  sockets.  These  caused  an  abscess  to  form, 
and  this  was  followed,  for  a  short  time,  by  a  subsidence  of 
the  pain,  which,  however,  soon  returned,  and  a  dull,  heavy 
sensation  was  felt  in  the  antrum  of  the  affected  side.  From 
thence  the  pain  extended  to  the  eye  and  ear.  The  gums  at 
length  became  tumefied,  and  the  pain  less  constant ;  the 
patient,  although  five  teeth  were  in  the  meantime  extracted, 
remained  in  this  condition  for  five  years.  At  this  time,  1756, 
M.  Beaupreau,  who  was  consulted,  found,  on  examination, 
that  the  gums  where  the  first  tooth  had  been  extracted,  had 
not  entirely  united,  and  a  small  tubercle  had  formed,  from 
which  a  fluid  of  a  bad  smell  and  reddish  color  was  dis- 
charging itself.  He  introduced  a  probe  into  the  fistulous 
hole  of  the  tubercle,  which  after  having  overcome  some  ob- 
stacle that  at  first  impeded  its  passage,  penetrated  the  an- 
trum. The  opening  was  enlarged  and  mercurial  water 
applied  to  the  carious  bone,  but  it  soon  closed^  and  the 
pain  which  liad  ceased,  returned.  Injections  were  resorted 
to.  These  discharged  themselves  in  part  through  the  nasal 
opening,  and  the  patient  continued  in  this  way  until  an  ex- 
foliation of  the  bone  took  place,  when  a  cure  was  effected. 

The  cause  of  the  disease  in  this,  as  in  the  preceding  cases, 
was  alvcolo-dental  irritation,  and  a  cure  would  at  once  have 
been  accomplished  by  the  removal  of  the  roots  of  the  tooth 
that  had  been  left  in  their  sockets,  as  was  proven  by  the  fact 
that  it  was  not  until  they  were  thrown  off  with  their  ex- 
foliated alveoli,  that  it  was  effected. 

In  alluding  to  these  and  similar  cases,  Bordenave  con- 
cludes there  are  not  many  cases  where  the  extraction  of 
teeth  simply,  will  suffice  to  effect  a  cure.  This  inference,  to 
say  the  least  of  it,  is  unfair,  for  in  the  case  last  given, 
it  was  to  the  presence  of  the  routs  of  a  tooth,  that  had  been 


582  TREATMENT   OF   PURULENT   SECRETIONS,  &C. 

fractured  in  an  attempt  to  extract  it,  and  left  in  their  sock- 
ets, that  the  affection  was  attributable,  and  we  have  good 
reason  to  believe,  that  the  cure  was  wholly  owing  to  their 
removal. 

The  history  of  the  following  exceedingly  interesting  case, 
which  was  communicated  to  the  Faculty  of  Medicine,  by 
Professor  Dubois,  is  contained  in  the  eighth  number  of  their 
bulletin  for  the  year  1813,  and  also  in  Boyer's  work  on 
Surgical  Diseases. 

Case  6th.  Upon  a  child  between  seven  and  eight  years 
old,  at  the  base  of  the  ascending  apophysis  of  the  superior 
maxillary  bone,  a  small  hard  round  tumor  of  the  size  of  a 
walnut,  was  perceived  by  its  parents.     About  a  year  after, 
the  child  fiell  upon  its  face,  and  caused  a  considerable  dis- 
charge of  matter  from  its  nose,  at  the  same  time  bruising 
the  tumor.     No  other  injury  was  produced,  and  the  tumor 
did  not  increase  perceptibly  in  size,  from  the  eighth  to  the 
fifteenth  year.     During  the  next  year,  however,  it  sensibly 
augmented,  and  from  the  sixteenth  to  the  eighteenth  year, 
it  attained  so  great  a  volume  that  the  floor  of  the  orbit  was 
elevated,  which  caused  a  diminution  in  the  size  of  the  eye, 
and  restricted  the  motions  of  the  eyelids.     The  arch  of  the 
palate  was  depressed  and  the  nasal  fossa  almost  closed.    The 
nose  was  forced  to  the  right  side  of  the  upper  part  of  the 
tumor,  and  there  was  a  considerable  elevation  beneath  the 
suborbital  fossa.     The  skin  below  the  inferior  eyelid  was  of 
a  violet  red  color,  and  very  tense.     The  upper  lip  was  ele- 
vated, and  the  gums  on  the  left  side  protruded  beyond  those 
on  the  other  side  of  the  arch.     Respiration  was  painful,  and 
the  patient  spoke  with  difficulty.     Sleep  was  laborious,  and 
mastication  was  attended  with  pain.     "In  this  state,"  says 
M.  Boyer,  "he  was  seen  by  M,  Dubois,  September  1st,  1802, 
but  as  he  was  not  able  to  determine  on  the  proper  operation, 
M.  Sabatier,  M.  Peletan  and  himself  were  called  in.     It  was 
the  ojjinion  of  all,  that  there  was  a  fungous  tumor  of  the 
antrum,  and  for  the  removal  of  this,  M.  Dubois  was  re- 
quested to  make  choice  of  his  own  method  of  operating. 


TREATMENT   OE   PURULENT   SECRETIONS,    &C.  583 

A  fluctuation  was  felt  behind  the  upper  lip,  and  this  de- 
termined M.  Dubois  to  commence  the  operation  by  making 
an  incision  there.  This  was  followed  by  a  discharge  of  a 
large  quantity  of  a  glairy  lymphatic  substance.  Through 
this  opening  a  sound  was  introduced  into  the  antrum,  and 
to  M.  Dubois'  surprise,  this  cavity  contained  no  tumor,  but 
upon  moving  the  sound  about,  it  struck  upon  a  hard  sub- 
stance, in  the  most  elevated  part  of  the  sinus,  which,  on  be- 
ing removed,  proved  to  be  a  canine  tooth.  Preparatory, 
however,  to  its  extraction,  two  incisors  and  one  molar  were 
removed  and  their  alveoli  cut  away.  Injections  were  after- 
wards employed  and  the  patient  was  soon  restored  to  health. 

It  is  not  necessary  to  stop  to  inquire  how  this  tooth  got 
into  the  antrum  ;  aberrations  of  this  sort  in  the  growth  of 
the  teeth  are  frequently  met  with,  and  some  precisely  simi- 
lar instances  have  already  been  referred  to.* 

In  all  the  cases  which  have  as  yet  been  noticed,  the  affec- 
tion was  traceable  to  local  irritation,  and  in  all,  except  the 
last,  it  had  originated  in  the  alveolar  ridge.  The  following 
case  of  muco-purulent  engorgement  may  be  thought  by  some 
to  have  been  occasioned  by  a  different  cause.  Yet,  there 
are  circumstances  connected  with  the  history  of  even  this 
case,  that  go  to  justify  the  belief,  if  the  teeth  had  been  in  a 
healthy  condition  the  affection  would  not  have  been  pro- 
duced. 

Case  7th.  Mr.  G -,  a  laborer,    a3t.  about  thirty,  of  a 

decidedly  scorbutic  habit,  applied  in  the  spring  of  1834,  to 
to  an  eminent  medical  gentleman  of  Baltimore,  to  obtain 
his  advise  concerning  an  affection  of  the  left  side  of  his  face, 
under  which  he  had  been  laboring  for  several  months.  The 
physician  to  whom  he  applied,  after  having  examined  the 
case,  came  to  the  conclusion,  that  it  was  mucous  engorge- 
ment of  the  maxillary  sinus,  and  requested  him  to  call  upon 
us,  and  have  one  of  his  molar  teeth  extracted,  and  the  floor 
of  the  antrum  through  its  alveolus  pierced.     He  at  the  same 

*  Vide  Mem.  de  TAcademie  de  Chirurg.,  vol.  v,  Mem.  257. 


584  TREATMENT   OF   PURULENT   SECRETIONS,    AC. 

time  desired,  that  if  his  opinion  in  regard  to  the  nature  of 
the  disease  proved  to  be  correct,  we  should  take  charge  of  the 
case  altogether.  On  examining  his  mouth,  we  discovered 
that  nearly  all  the  teeth  of  both  jaws,  the  gums  and  alveo- 
li were  extensively  diseased,  and,  on  inquiry,  obtained  from 
him  the  following  statement  with  regard  to  the  commence- 
ment and  progress  of  the  affection. 

About  six  months  previous  to  this  time,  having  been  ex- 
posed, while  pursuing  his  ordinarj'  avocations,  to  very  in- 
clement and  several  sudden  changes  of  weather,  he  con- 
tracted a  severe  cold  ;  in  consequence  of  which,  he  was  con- 
fined to  his  bed  for  several  days  ;  during  this  time,  he  was 
twice  bled,  took  two  cathartics,  and  other  medicines. 

The  disease  at  first  concentrated  itself  in  his  head,  face, 
and  jaws^  which,  at  the  expiration  of  eight  or  ten  days,  was 
subdued  by  the  above  treatment,  with  the  exception  of  the 
pain  in  his  left  cheek,  and  soreness  in  the  upper  teeth  of 
the  same  side.  The  pain  in  his  cheek,  although  not  con- 
stant, still  continued  ;  the  nasal  cavity  of  that  side  ceased 
to  be  supplied  with  its  usual  secretion,  the  teeth  became 
more  sensitive  to  the  touch,  and,  finally,  at  the  end  of  four 
months,  a  slight  protuberance  of  the  cheek  was  observable, 
accompanied  by  a  tumor  upon  the  left  side  of  the  palatine 
arch,  which,  when  we  first  saw  him,  had  attained  to  half 
the  size  of  a  black  walnut,  and  it  was  by  the  fluctuation  felt 
here,  that  the  physician  whom  he  first  consulted,  was  in- 
duced to  suspect  the  true  nature  of  the  disease. 

Acting  under  the  direction  of  the  medical  gentleman  in 
whose  care  the  j^atient  had  placed  himself,  we  extracted  the 
second  left  superior  molar,  and  through  its  alveolus  pene- 
trated the  antrum  by  means  of  a  straight  trocar,  after  the 
withdrawal  of  which,  a  large  quantity  of  glairy,  fetid  mu- 
cous fluid  was  discharged.  The  perforation  was  kept  open 
by  means  of  a  bougie,  secured  with  a  silk  ligature  to  an  ad- 
joining tooth,  as  recommended  by  Deschamps,  and  the  an- 
trum injected  three  times  a  day.  At  first,  simply  with  rose 
water,  to  which  a  small  quantity  of  sulphate  of  zinc  was  af- 


TREATMENT  OF  PURULENT  SECRETIONS,  &C.  585 

torwards  added.  By  tliis  treatment,  the  lining  membrane 
of  the  antrum,  at  the  expiration  of  five  weeks,  was  restored 
to  health,  and  the  secretions  that  escaped  through  the  per- 
foration, no  longer  exhaled  fetid  odor. 

The  patient,  not  experiencing  any  inconvenience,  with- 
drew the  bougie,  and  allowed  the  aperture  to  close.  In 
about  two  months,  he  again  presented  himself  to  the  author 
similarly  affected  as  when  he  first  saw  him.  He  now  ex- 
tracted the  first  superior  left  molar,  and  perforated  the  an- 
trum through  the  alveolus,  and  a  quantity  of  fetid  mucous 
fluid  was  again  discharged  ;  the  dens  sapienti^,  and  the 
first  and  se.cond  bicuspids  of  the  affected  side,  which  were 
carious,  were  also  extracted.  Injections  of  sulphate  of  zinc 
and  rosewater^  diluted  tincture  of  myrrh,  diluted  port  Avine, 
and  a  decoction  of  nut  galls,  were  alternately  employed  for 
three  mouths,  at  the  expiration  of  which  time,  the  nasal 
opening,  which  had  been  previously  closed,  was  re-estab- 
lished, and  a  perfect  cure  efiected. 

The  condition  of  the  teeth  in  the  case  just  narrated,  may 
not  be  thought  to  have  exerted  any  agency  in  the  pro- 
duction of  the  affection  of  the  antrum,  but  there  are  cir- 
cumstances connected  with  its  progress  that  would  seem  to 
justify  a  different  conclusion. 

The  presence  of  decayed  teeth  beneath  the  sinus,  may 
not  only  have  contributed  to  aggravate  the  morbid  action 
lighted  up  by  the  cold  which  he  had  taken,  but  may  also 
have  caused  it  to  locate  itself  in  this  cavity ;  and  the  fact 
that  the  inflammation  of  the  lining  membrane  and  the  ob- 
literation of  the  nasal  opening  continued  until  they  were  re- 
moved, would,  at  least,  seem  to  warrant  such  an  inference. 
That  the  injections  were  beneficial,  we  do  not  doubt,  but 
that  the  cure  was  affected  by  them,  no  one,  we  think,  will 
dare  to  affirm.  We  are  far  from  believing  that  the  presence  of 
the  decayed  teeth  was  the  sole  cause  of  the  disease  of  the 
antrum ;  that  they  contributed  to,  and  protracted  it,  we 
cannot  hesitate  to  believe,  and  but  for  the  increased  excita- 
bility, and,  perhaps,  actual  inflammation,  induced  in  the 
38 


586  TREATMENT  OF    PURULENT  SECRETIONS,   <tC. 

mucous  membrane,  by  the  exposure  of  the  patient  to  in- 
clement and  sudden  transitions  of  weather,  it  is  probable 
the  sinus  would  never  have  become  affected.  We  think  it 
not  unlikely  that,  notwithstanding  the  disturbance  which 
may  have  been  originated  in  it  by  this  cause,  no  very  seri- 
ous or  lasting  morbid  effect  would  have  been  produced, 
if  the  teeth  and  alveoli  had  been  in  a  perfectly  healthy 
condition. 

The  particulars  of  the  following  highly  interesting  case 
were  communicated  to  the  author  by  Dr.  L.  Roper,  dentist, 
of  Philadel23hia,  in  a  conversation  which  he  had  with  him 
in  1845. 

Case  8th.    Miss  M ,   a  young  lady  from   the  West 

Indies,  of  about  fourteen  years  of  age,  had  a  fistulous  open- 
ing beneath  the  right  orbit,  communicating  with  the  max- 
illary sinus.  By  means  of  a  probe  introduced  through  the 
opening  into  this  cavity,  the  apices  of  the  roots  of  the  first 
superior  molar  could  be  distinctly  felt. 

Medical  aid  was  sought  at  an  early  stage  of  the  disease, 
but  as  no  permanent  benefit  resulted  from  the  treatment 
adopted,  the  young  lady,  at  the  expiration  of  nine  months, 
was  brought  by  her  father  to  Philadelphia,  and  in  the 
spring  of  1831,  placed  under  the  care  of  the  late  Dr.  Phy- 
sick,  who,  suspecting  the  affection  of  the  antrum  had  re- 
sulted from,  and  was  still  kejit  up  by,  irritation,  produced 
by  the  first  superior  molar  of  the  affected  side,  which  was 
considerably  decayed,  directed  her  to  be  taken  to  Dr. 
Roper,  who,  concurring  with  him  in  opinion,  at  once  ex- 
tracted the  carious  tooth.  The  operation  was  followed  by 
the  immediate  discharge  of  a  large  quantity  of  thick, 
muddy,  and  greenish  matter.  The  fistula  under  the  orbit 
soon  closed,  and  without  further  treatment,  a  perfect  cure 
was  accomplished  in  the  course  of  a  few  weeks. 

The  foregoing  are  all  the  particulars  whicli  we  could  ob- 
tain concerning  this  interesting  case.  We  have  no  doubt 
if  all  the  circumstances  connected  with  its  early  history 
were  known,  it  would  be  found  to  have  resulted  from  in- 


TREATMENT   OF    PURULENT   SECRETIONS,    <feC.  587 

flammation  of  the  lining  membrane  of  the  antrum,  caused 
by  irritation  in  the  socket  of  the  tooth  which  was  extracted. 
This  opinion  is  sustained  by  the  facts,  that  this  tooth  was 
affected  with  caries,  and  that  its  removal  was  followed  by 
the  immediate  cure  of  the  disease. 

In  Bordenave's  collection  of  cases  of  diseases  of  the  max- 
illary sinus,  published  in  the  Memoirs  of  the  Royal  Academy 
of  Surgery,  there  are  several  examples  similar  to  the  one 
just  narrated.    We  subjoin  a  description  of  the  two  following : 

Case  9th.  A  servant  of  the  count  of  Maurepes  had  been 
afflicted  for  six  months  with  a  fistula  upon  the  left  cheek,  a 
little  below  the  orbit,  which  penetrated  the  maxillary  sinus^ 
caused  by  the  spontaneous  opening  of  an  abscess.  The 
third  and  fourth  molars,  (which  are  the  first  and  second  ac- 
cording as  the  teeth  are  now  designated,)  both  of  which 
were  considerably  decayed,  were  extracted  by  M.  Hevin. 
As  there  were  no  openings  through  the  alveoli^  he  per- 
forated one  with  a  trocar  ;  this  opening  gave  vent  to  a  great 
quantity  of  putrid  sanies,  and  did  not  close  for  more  than 
a  year  after  it  was  made.  The  fistula  of  the  cheek  healed 
in  about  ten  days. 

Case  10th,  In  1717,  a  soldier  of  the  regiment  of  Bassigny, 
who  had  for  a  long  time  a  fistula  in  his  cheek  penetrating 
into  the  maxillary  sinus,  was  treated  for  it  at  the  Hotel 
Dieu,  of  Montpelier.  The  matter  settling  near  the  orifice 
of  the  fistula,  prevented  it  from  closing.  Mr.  Lamourier, 
on  examining  the  mouth  of  the  soldier,  perceived  that  the 
second  superior  nfolar  was  decayed;  this  he  extracted  and 
profited  by  the  alveolar  cavity,  in  opening  the  base  of  the 
sinus.  The  fistula  of  the  cheek  was  by  this  means  cured  in 
a  few  days,  but  the  counter  opening  was  not  immediately 
permitted  to  close. 

In  cases  of  fistula  resulting  simply  from  engorgement  of 
the  sinus,  the  treatment,  as  has  been  shown  by  the  result  of 
that  in  the  foregoing  cases,  consist  in  the  formation  of  a 
counter  opening,  which  should  always  be  afiected  at  the 
most   dependent  part  of  the  cavity,   and    in    the  removal 


588  TREATMENT  OP    PURULENT  SECRETIONS,    AC. 

of  all  sources  of  local  irritation.     Injections  should  also  be 
employed. 

In  the  cases  thus  far  presented^  we  have  selected  such  as 
were  not  complicated  with  abscesses_,  ulceration  of  the  lining 
membrane,,  or  caries  of  the  surrounding  osseous  walls ;  but 
to  the  existence  of  the  two  last,  the  affections,  on  which  we 
have  been  treating,  often  give  rise.  We  will  not  extend  our 
remarks  further  upon  mucous  engorgement  and  purulent 
conditions  of  the  secretions  of  this  cavity.  The  next  form 
of  disease  on  which  we  propose  to  speak,  is  abscess — an  af- 
fection, differing  in  all  its  characteristics  from  those  thus 
far  treated. 


I 


CHAPTER     FOURTH. 

ABSCESS    OF    THE    MAXILLARY    SINUS. 

The  formation  of  abscess  in  any  other  part  of  the  max- 
illary sinus  than  at  the  extremity  of  the  root  of  a  tooth 
which  has  penetrated  the  cavity,  is  exceedingly  rare.  There 
are  but  two  well  authenticated  cases  in  which  it  has  liap- 
pened,  so  far  as  we  have  been  able  to  a8certain_,  on  record. 
One  of  these  is  described  by  Mr.  Thomas  Bell,*  and  the 
other  by  Bordenave.f  The  abscess  in  both  instances  was 
seated  in  the  upper  part  of  the  antrum,  beneath  the  orbit. 
But  as  we  shall  have  occasion  to  refer  to  these  cases  again, 
it  is  not  necessary  to  say  more  concerning  them  at  this 
time. 

Dr.  HuUihen,  in  a  well  written  article  in  the  American 
Journal  of  Dental  Science,!  contends  that  abscess  of  the 
antrum,  as  well  as  alveolar,  consists  in  the  effusion  of 
pus^  formed  in  the  pulp  cavity  of  a  tooth,  between  the  bone 
and  lining  membrane."  That  this  view  of  the  subject  is 
incorrect,  is  proven  by  the  fact,  that  abscesses  are  almost  as 
frequently  formed  in  the  sockets  of  dead  teeth  as  living 
teeth.  The  matter  from  alveolar  abscess,  in  those  cases 
where  the  plate  of  bone  intervening  between  the  extremity 
of  the  root  of  a  superior  molar  or  bicuspid,  is  thinner  than 
the  surrounding  osseous  wall,  often  escapes  through  it  into 
this  cavity,  after  having  first,  as  Dr.  H.  justly  remarks,  ef- 
fused itself  between  the  bone  and  lining  membrane.  In  this 
case,  it  cannot  projjerly  be  termed  an  abscess  of  the  antrum. 
Although  the  matter  escapes  into  this  cavity,  and,  in  con- 

*  Vide  Anatomy,  Physiology  and  Diseases  of  the  Teeth. 

t  Vide  Mem.  de  I'Acad.  Royale  de  Chirurg.,  toI.  12,  ed.  12mo,  obs.  xi,  p.  31. 

I  Vide  vol.  ii,  p.  179. 


590  ABSCESS    OF    THE    MAXILLARY    SINUS. 

sequence,  becomes  involved  in  disease,  yet  the  disease  hav- 
ing originated  in  the  alveolus  of  a  tooth,  which  is  still  its 
principal  seat,  is,  in  the  strictest  sense  of  the  term,  alveo- 
lar abscess.  It  sometimes  happens  that  pus  from  an  ab- 
scess, formed  in  the  socket  of  a  superior  molar,  discharges 
itself  into  this  cavity,  and  escapes  through  the  opening  into 
the  nose.  The  pulp  may  suppurate,  and  the  matter  be  con- 
fined in  the  cavity  of  the  tooth  for  a  long  time,  or  be  dis- 
charged through  a  decayed  opening  in  the  crowu_,  commu- 
nicating with  the  internal  cavity,  without  causing  alveolar 
abscess.  The  purulent  matter  contained  in  the  sac  at  the 
extremity  of  the  root  of  a  tooth,  is  not  always  formed,  as 
Dr.  H.  supposes,  in  the  cavity  of  the  tooth.  The  quantity 
of  pus  discharged  from  an  alveolar  abscess  is  oftentimes 
greater  than  that  which  could  be  formed  by  the  suppuration 
of  the  soft  tissues  contained  within  the  cavity  of  a  tooth, 
and_,  besides,  after  this  matter  has  been  discharged,  it  can- 
not again  be  reproduced  here,  and,  consequently,  any  mat- 
ter which  may  afterwards  accumulate  in  the  cavity  of  the 
tooth,  must  be  secreted  by  the  soft  parts  about  the  ex- 
tremity of  the  root.  Again,  abscesses  often  form  at  the  ex- 
tremities of  the  roots  of  teeth,  after  their  internal  cavi- 
ties have  been  tilled  to  their  very  apices.  The  alveolo- 
dental  membrane  at  the  apex  of  the  root  of  a  tooth,  around 
the  nerve  cord_,  are  more  vascular,  and  endowed  with 
greater  nervous  sensibility,  than  at  any  other  part,  conse- 
quently, the  inflammatory  action  here  is  always  the  great- 
est, and  it  is  here  that  suppuration  first  takes  place. 

The  apices  of  the  roots  of  the  first  and  second  superior 
molars,  when  they  do  not  actually  perforate  the  floor  of  the 
antrum,  are  often  above  its  level^  and  covered  b}''  only  a 
very  thin  shell  or  cap  of  bone,  and  hence,  in  case  of  abscess 
in  one  of  these,  although  strictly  alveolar,  the  matter  is 
more  liable  to  make  for  itself  a  passage  into  this  cavity, 
than  through  the  gum  into  the  mouth.  When  this  hap- 
pens, it  gives  rise  to  inflammation  of  the  lining  membrane, 
causing  its  secretions  to  become  more  or  less  vitiated,  and 


ABSCESS    OF    THE    MAXILLARY    SINUS.  591 

often  leads  to  an  erroneous  opinion  concerning  the  true  seat 
of  the  disease. 

It  is  only  when  the  root  of  a  tooth  actually  penetrates  the 
floor  of  the  antrum,  or  the  tubercle  at  its  apex  is  actually 
situated  in  it,  that  the  abscess  can  properly  be  said  to  be  of 
this  cavity.  When  the  root  does  penetrate  it,  the  tubercle^ 
although  formed  at  its  apex  around  the  nerve  cord,  as  it  is 
commonly  called,  is  between  the  lining  membrane  and  peri- 
osteal tissue,  both  of  which,  in  the  immediate  vicinity,  be- 
come directly  involved  in  inflammation,  and  this  sometimes 
extends  to  every  part  of  the  cavity,  causing  in  some  in- 
stances, obliteration  of  the  nasal  opening.  This,  however, 
does  not  often  occur^  but  when  it  does,  is  followed  by  en- 
gorgement of  the  sinus,  occasionally,  by  ulceration  of  the 
lining  membrane  and  disease  in  the  surrounding  parts. 

It  is  sometimes  the  case,  that  the  plate  of  bone  inter- 
vening between  the  extremity  of  the  root  of  a  tooth,  around 
which  a  tubercle  has  formed,  and  the  antrum,  is  destroyed, 
and  the  tubercle,  instead  of  being  wholly  confined  within 
the  alveolus,  is  forced  up,  as  it  enlarges,  almost  entirely 
into  this  cavity.  The  inflammation,  after  having  attained 
a  certain  height,  is  succeeded  by  suppuration,  and  the  se- 
cretion of  pus  goes  on  until  the  sac  bursts,  when  the  matter 
is  discharged,  and,  mixing  with  the  mucous  secretions  of 
this  cavity,  ultimately  escapes  with  them  through  the  natU' 
ral  opening  into  the  nose. 

As  it  regards  the  morbid  efi'ects  produced  upon  the  lining 
membrane  and  surrounding  bony  parietes  of  the  antrum,  by 
an  abscess  of  this  kind,  it  is  of  little  consequence  whether  it 
be  formed  in  it,  if  the  matter  be  discharged  there,  or  in  the 
alveolus  of  the  tooth  that  gave  rise  to  it.  The  efi'ects  are 
nearly  the  same  in  one  case  as  in  the  other.  If  the  general 
health  of  the  patient  be  good,  and  the  natur,;!  opening  of 
the  sinus  remain  pervious,,  they  seldom  assume  nn  alarming 
character;  under  other  and  less  favorable  circumstances, 
the  most  dangerous  and  aggravated  forms  of  disease  may 
vesult  from  abscess  in  either  place. 


592  SYMPTOrrlS    OF    ABSCESS. 


S  Y  M  P  T  0  M  S . 

In  the  incipient  or  forming  stages  of  abscess  of  the  max- 
illary sinus,  the  symptoms  are  similar  to  those  that  charac- 
terize inflammation  of  the  lining  membrane,  or  violent  in- 
flammatory tooth-ache.  The  joain  is  generally  most  severe 
in  the  upper  part  of  the  alveolar  ridge,  above  one  of 
the  molar  or  bicuspid  teeth.  From  thence,  it  often  extends 
to  the  lower  part  of  the  orbit,  ear,  temple,  muscles  of  the 
cheek  and  scalp.  It  is  more  or  less  constant,  and  a  throb- 
bing sensation  is  felt  high  up  in  the  alveolar  border  beneath 
the  cheek.  If  the  abscess  is  seated  at  the  apex  of  the  root 
of  a  tooth,  this  organ  will  appear  slightly  elongated  and 
sore  to  the  touch;  the  cheek,  in  most  instances,  is  slightly 
tumefied,  and  more  or  less  flushed. 

The  pain,  after  having  continued  for  several  days,  is  suc- 
ceeded by  suppuration,  when  it  immediately  subsides. 
Slight  paroxysms  of  cold  and  heat  are  now  felt,  and  if  the 
natural  opening  of  the  antrum  is  not  closed,  purulent  mat- 
ter will,  occasionally,  be  discharged. 

If  the  abscess  is  seated  in  any  other  part  than  the  base  of 
the  antrum,  the  symptoms  may  differ  in  some  respects  from 
the  foregoing.  If  purulent  matter,  or  mucus  mixed  with 
pus,  be  discharged  from  the  nostril  of  the  affected  side, 
when  the  patient  inclines  his  head  to  the  opposite,  or  makes 
a  sudden  and  forcible  expiration  through  it,  while  the  other 
is  closed,  the  existence  of  abscess  in  this  cavity  will  be  very 
conclusively  indicated. 

The  abscess  having  burst,  pus  will  be  discharged  from 
time  to  time,  for  several  days,  which  will  escape  through  the 
nasal  opening,  with  hardened  flocculi  or  other  foreign  mat- 
ter, and  then  it  will  cease  altogether  or  very  nearly.  The 
disease,  however,  if  the  irritant  which  gave  rise  to  it  still 
remains,  is  by  no  means  cured.  A  recurrence  of  it  is  liable 
to  take  place  every  time  the  patient  takes  cold,  when  all  the 
symptoms  just  described  will  be  again  experienced,  and  each 


TREATMENT   OF   ABSCESS.  593 

succeeding  attack  leaves  the  parts  implicated  in  the  disease 
in  a  more  unhealthy  condition,  and^  as  a  consequence,  more 
susceptible  of  being  acted  upon  by  morbid  irritants.  Sup- 
puration, also,  at  each  successive  attack,  takes  place,  and 
the  pus  gradually  assumes  a  more  unhealthy  character. 

CAUSES. 

It  will  not  be  necessary  to  say  much  concerning  the  causes 
of  abscess  of  the  antrum.  It  is  sufficient  to  state,  they  are 
the  same  as  those  of  tooth-ache,  namely,  inflammation  of 
the  alveolo-dental  periostea  or  inflammation  of  the  lining 
membrane  of  this  cavity.  It  is  to  the  presence  of  one  or 
other,  or  both  of  these  that  it  is  attributable.  These  may 
be  occasioned  by  caries  of  the  teeth,  or  a  dead  or  loose  tooth, 
or  a  blow  ujDon  the  cheek,  or  by  exposure  to  sudden  changes 
of  weather.  Other  causes  may  sometimes  be  concerned,  but 
the  foregoing  are  the  principal,  and  all  it  is  necessary  to 
enumerate. 

TREATMENT. 

In  the  cure  of  abscess  of  the  maxillary  sinus,  as  well  as  that 
of  a  muco-purulent  condition  of  its  secretions  or  engorge- 
ment, the  first  and  most  important  indication  to  be  fulfilled 
is  to  obtain  vent  for  the  matter  from  the  inferior  part  of  the 
cavity.  The  best  method  of  doing  this  has  been  described, 
and  it  is  unnecessary  to  recapitulate  the  directions  already 
given  for  the  accomplishment  of  this  object. 

The  formation  of  abscess  might,  however,  in  almost  every 
instance  be  prevented  by  the  timely  adoption  of  proper 
treatment.  On  tlie  occurrence  of  severe^  deep-seated  and 
throbbing  pain  in  the  upper  part  of  the  alveolar  ridge,  or 
just  above  it  in  the  region  of  the  antrum,  such  as  has  been 
described  as  attending  the  formation  of  abscess  in  this 
cavity,  or  that  of  the  alveolus  of  a  superior  molar;  or  if  the 


594  TREATMENT   OF   ABSCESS. 

tooth  directly  beneath  the  place  where  it  was  first  felt,  be 
considerably  decayed,  or  its  lining  membrane  exposed  ;  or 
if  it  be  dead,  loose,  or  the  socket  much  diseased,  it  should 
be  immediately  extracted.  By  this  simple  operation,  the 
formation  of  abscess  not  only  in  the  socket,  but  also  in  the 
antrum,  may,  in  almost  every  instance,  be  prevented. 

The  curative  indications,  if  the  abscess  is  of  recent  forma- 
tion, and  has  resulted  from  the  presence  of  a  diseased  tooth, 
are  similar  to  the  preventive.  The  first  thing  to  be  done  is 
to  remove  the  tooth  that  caused  it,  and  if  this  operation  is 
not  delayed  too  long,  it,  in  most  instances,  will  be  all  that 
is  necessary  to  efi'ect  a  cure.  In  addition  to  this.  Dr.  Hulli- 
hen  recommends  the  perforation  of  the  antrum  ;*  but  in 
those  cases  where  the  abscess  has  formed  at  the  apex  of  the 
root  of  a  molar,  this  is  not  necessary  ;  because  in  all  sucb 
cases,  the  alveolus  communicates  with  this  cavity,  so  that 
on  the  removal  of  the  tooth,  there  will  be  a  sufficiently 
large  opening  communicating  with  it ;  besides,  the  tubercle 
or  sac,  although  situated  within  the  sinus,  is  usually  brought 
away  with  the  tooth. 

When  the  abscess  has  been  of  long  standing,  and  the  lin- 
ing membrane  of  the  antrum  has  become  seriously  affected, 
in  addition  to  the  removal  of  the  tooth,  other  treatment  will 
have  to  be  resorted  to.  The  opening  into  the  antrum,  if 
necessary,  should  be  enlarged,  and  it  should  be  prevented 
from  closing  until  the  health  of  the  lining  membrane  is  re- 
stored. For  the  promotion  of  this,  injections,  such  as  have 
been  already  recommended,  will  be  found  serviceable. 

In  cases  of  simple  abscess  of  the  antrum,  seated  at  the 
apex  of  the  root  of  a  superior  molar,  we  have  never  found  it 
necessary  to  adopt  any  other  treatment  than  the  foregoing. 
It  may,  however,  in  some  instances,  be  necessary  to  remove 
more  than  one  tooth. 

We  might,  if  it  were  necessary,  give  the  history  of  sev- 
eral interesting  cases  of  abscess  of  this  cavity,  which  had 

f  American  Journal  of  Dental  Science,  rol.  ii,  p.  182. 


TREATMENT   OF   ABSCESS.  595 

originated  at  the  extremity  of  the  roots  of  teeth,  but  as  the 
treatment  is  so  simple,  it  would  be  enlarging  this  portion  of 
our  work  to  no  purpose  to  do  so. 

But  before  we  conclude  our  remarks  upon  abscess  of  this 
cavity,  we  will  give  the  history  of  one  case  to  which  allusion 
has  before  been  made.  Tlie  following  detailed  statement 
we  quote  from  Mr.  Bell's  treatise  on  the  teeth. 

Case  11th.  ''Mary  B ,  aged  eighteen,  of  an  unheal- 
thy and  somewhat  strumous  aspect,  of  languid  disposition, 
and  of  retiring  and  timid  liabits,  came  under  my  care  on  tbe 
3d  of  January,  1817,  in  consequence  of  a  severe  and  con- 
tinued pain  on  the  left  side  of  the  face,  of  a  dull  heavy  char- 
acter, and  apparently  deep-seated  ;  but  occasionally  darting 
in  acute  paroxysms  across  the  face  towards  the  nose.  The 
cheek  was  swollen^  and  the  palate  somewhat  enlarged. 
About  a  year  before,  the  first  superior  molar  of  that  side 
had  been  extracted  on  account  of  severe  pain  in  the  face, 
but  without  producing  any  relief,  and  the  pain  was  conse- 
quently attributed  to  rheumatism,  from  which  complaint 
she  had  long  suffered  to  a  great  degree,  in  the  shoulder,  hip, 
and  other  joints,  and  for  which  she  had  been  under  the  care 
of  many  medical  practitioners,  both  in  London  and  Bath, 
having  been  sent  to  the  latter  place  for  the  use  of  the  waters. 
When  I  first  saw  her,  the  general  health  was  much  de- 
ranged :  the  stomach,  bowels  and  liver  performed  their 
functions  very  imperfectly  ;  and  the  uterus  partook  of  the 
general  sluggishness  of  tlie  system,  menstruation  being 
almost  wholly  suppressed,  and  the  periods  only  indicated 
by  increased  indisposition,  and  especially  by  an  exacerba- 
tion of  the  pain  in  the  face. 

"No  discharge  had  taken  place  from  the  nose,  biit  from 
the  nature  and  situation  of  the  pain,  the  direction  of  its 
paroxysms,  the  enlargement  of  the  cheek  and  palate,  and 
from  an  occasional  trifling  discharge  of  pus  from  the  alveolus 
of  the  tooth  which  had  been  extracted,  I  could  not  doubt 
that  the  antrum  was  the  seat  of  the  disease.  On  exam- 
ining the  teeth,  I  found  that  the  second  bicuspid  was  also 


596  TREATMENT   OF   ABSCESS, 

diseased,  and  as  it  liad  at  times  occasioned  considerable 
pain,  I  extracted  it  witli  the  view  of  removing  every  possi- 
ble source  of  irritation. 

''Six  leeches  were  ordered  to  be  applied  to  the  face,  and 
afterwards  the  continued  application  of  a  cold  lotion.  Med- 
icines were  also  administered  with  reference  to  the  general 
health,  both  as  regarded  the  digestive  and  uterine  functions  ; 
and  on  January  Yth  I  dejtermined  on  puncturing  the  antrum. 
I  consequently  introduced  the  trochar  through  the  anterior 
alveolar  cavity  of  the  first  molar,  and  found  that  when  the 
instrument  came  in  contact  with  the  lining  membrane,  the 
most  acute  pain  was  produced,  indicating  the  existence  of  a 
hio-h  deorree  of  inflammation  in  that  structure.  On  with- 
drawing  the  trochar,  when  the  antrum  was  freely  opened,  I 
was  surprised,  and  a  little  disappointed  at  finding  that  not 
the  smallest  discharge  made  its  appearance.  There  was  a 
small  quantity  of  glairy  mucus,  but  nothing  more.  I  intro- 
duced the  blunt  end  of  a  probe,  and  found  that  the  opening 
was  quite  free ;  but  on  passing  it  upwards  towards  the  orbit, 
its  passage  was  resisted  by  a  firm  elastic  substance,  which 
gave  the  impression  that  a  solid  tumor  existed  in  the  upper 
part  of  this  cavity,  and  which  produced  intolerable  pain  on 
being  pressed  with  the  probe.  I  now  injected  some  tepid 
water,  and  found  that  the  nasal  opening  was  pervious,  as 
the  water  passed  freely  into  the  nose.  As  the  operation 
had  produced  a  considerable  increase  of  pain,  and  as  the 
parts  appeared  a  good  deal  inflamed,  I  ordered  six  leeches 
to  be  applied,  the  bowels  to  be  freely  opened,  and  an  opiate 
to  be  taken  at  night. 

"January  9th.  The  pain  had  been  extremely  severe  ever 
since  the  operation,  with  scarcely  any  mitigation,  excepting 
for  a  few  '  ours  after  tlio  ap  lication  of  the  leeches.  A  probe 
now  introduced  into  the  antrum,  met  with  simihar  resist- 
ance, but  much  nearer  the  orifice  tlian  before,  proving  that 
the  tumor  had  increased  ;  and  on  injecting  Avarm  water, 
it  no  longer  passed  into  the  nose.  The  leeches,  the  aperient, 
and  the  opiate  were  repeated. 


TREATMENT   OF   ABSCESS.  597 

''January  11th.  The  pain  has  continued  without  cessation, 
and  no  sleep  has  been  produced  by  the  opium.  The  inflam- 
mation is  not,  apparently,  reduced.  Pulse  one  hundred, 
small  and  feeble.  The  palate  is  a  little  enlarged^  but  not 
more  so  than  might  be  accounted  for,  by  the  thickening  of 
the  integuments  by  inflammation.  I  could  now  distinctly 
feel  with  a  probe,  that  the  tumor  was  not  only  increased  in 
size,  but  that  it  had  become  softer,  yielding  in  some  mea- 
sure to  pressure,  and  conveying  the  impression  that  it  con- 
tained fluid.  I  therefore  introduced  a  sharp  pointed  instru- 
ment, which  with  a  little  force,  pierced  the  tumor,  and  a 
gush  of  pus  instantly  took  place,  with  immediate  relief  to 
the  symptoms. 

"Here,  then,  was  the  sac  containing  pus,  existing  doubt- 
less as  a  distinct  cyst,  the  result  of  inflammation  in  the 
membrane  ;  for  it  is  scarcely  probable  that  the  membrane 
itself  had  become  separated  from  its  attachment  by  the  for- 
mation of  pus  between  it  and  the  bone.  That  the  former 
was  the  true  situation  of  the  disease,  may  be  inferred  from 
the  fact  that  no  subsequent  caries  of  the  bone  took  place, 
which  would_,  undoubtedly,  have  been  the  case,  had  the 
matter  been  formed  in  contact  with  the  bone  ;  and  it  could 
scarcely  have  been  produced  between  the  mucous  membrane 
and  the  periosteum,  as  these  two  structures,  though  essen- 
tially distinct  from  each  other,  are  inseparably  connected. 
''The  pus  continued  to  be  discharged  for  a  day  or  two, 
and  then  entirely  ceased.  In  passing  the  probe  a  week  af- 
ter the  former  operation,  I  found  the  same  resistance  as  be- 
fore, and  in  the  same  situation  ;  the  cyst  was  again  punc- 
tured, and  again  the  pus  was  discharged.  This  alteration 
of  the  repletion  and  evacuation  of  the  cyst  regularly  recur- 
red for  a  considerable  time,  but  the  opening  into  the  nose 
did  not  again  become  stopped.  The  general  health,  how- 
ever, in  the  meanwhile,  improved,  and  the  pain  in  the  face 
was  greatly  diminished,  returning  only,  with  any  degree  of 
violence,  when  the  cyst  was  full. 

"At  length  the  repeated  perforation  of  the   sac,  followed 


598  TREATMENT   OF   ABSCESS. 

by  the  use  of  strong  astringent  injections,  and  aided  by  the 
remedies  that  were  directed  to  the  state  of  the  general  health, 
restored  the  antrum  to  a  healthy  condition  ;  the  menstrual 
disturbance  was  by  degrees  entirely  obviated,  and  the  stom- 
ach at  the  same  time  assumed  its  healthy  function  ;  but  it 
was  two  years  from  the  time  when  I  first  saw  her  before  she 
had  recovered  her  health,  which  at  the  best  was  never  ro- 
bust." 

There  is  a  case  described  by  Bordenave,  which,  in  many 
respects,  is  similar  to  the  foregoing,  but  having  adopted  a 
different  treatment^  the  cure  was  more  tardy.  It  was  ulti- 
mately, however,  effected.  For  the  particulars  of  the  case, 
the  reader  is  referred  to  a  Dissertation  of  the  author  on  the 
diseases  of  this  cavity,  page  86. 

Finally,  that  abscess  does  occasionally  form  in  other  parts 
of  the  antrum  than  the  base,  is  conclusively  proven  by  the 
cases  described  by  Bell  and  Bordenave.  It  is  true,  these 
are  the  only  ones  of  which  we  have  any  account,  nevertheless, 
they  establish  the  fact  that  it  is  possible  for  them  to  occur 
in  any  part  of  this  cavity. 


CHAPTER      FIFTH. 

ULCERATION  OF  THE  LINING  MEMBRANE  OF  THE  MAX- 
ILLARY SINUS. 

This  is  not  an  idiopatliic  affection.  It  is  always,  we  be- 
lieve, symptomatic  of  some  other  morbid  condition  of  the 
mucous  membrane  of  this  cavity,  and  often  gives  rise  to  some 
of  the  worst  and  most  aggravated  forms  of  disease,  to  which 
it  is  liable.  It  is  not  a  simple  disease,  but  is  complicated 
■with  the  one  that  caused  it,  and  often  with  some  other  to 
which  it  has  given  rise.  We  shall  treat  of  it,  however,  as 
a  separate  affection.  Its  attacks  are  preceded  by  a  purulent 
condition  of  the  fluids  of  the  antrum,  and  are  often  followed 
by  fungi,  and  sometimes  by  caries  of  the  surrounding  osseous 
walls.  The  membrane  covering  the  floor  of  the  cavity,  is 
usually  first  attacked ;  ulcers  having  formed  here,  they 
soon  extend  to  other  parts  of  the  sinus. 

Ulcers  of  this  cavity  present  as  great  a  variety  of  charac- 
ter as  do  those  of  other  parts  of  the  body.  Their  nature  is 
determined  by  the  state  of  the  constitutional  health  and  the 
causes  that  produce  them.  It  is  not  necessary  to  go  into  a 
minute  description  of  the  various  kinds  of  ulcers  that  occur 
in  this  cavity.  It  will  be  sufiicient  to  state  that  the  follow- 
ing varieties  have  been  met  with  :  namely,  the  simple,  or 
those  resulting  from  mechanical  injury  ;  the  fungous,  scor- 
butic, venereal^  cancerous,  gangrenous,  scrofulous,  invete- 
rate, carious,  &c. 

In  the  simpler  species  of  ulcer,  the  matter  is  of  a  thick 
consistence  and  nearly  white,  but  as  the  disease  increases  in 
malignancy,  it  becomes  thinner  and  varies  in  appearance 
from  transparent  to  a  dirty  brown,  yellow  or  black. 


600  SYMPTOMS   OF   ULCERATION. 


SYMPTOMS. 

Many  of  the  symptoms  attendant  upon  ulceration  of  the 
mucous  membrane  of  the  maxillary  sinus,  are  similar  to 
some  that  accompany  other  affections  of  this  cavity  ;  as,  for 
example,  deep-seated  heavy  pain  in  the  cheek  ;  occasional 
escape  of  matter  into  the  nose,  &c.  In  addition  to  constant 
pain  in  the  region  of  the  antrum^  the  following  symptoms 
may  he  enumerated.  The  escape  of  fetid  sanies  into  the 
nose  on  the  patient's  inclining  his  head  to  the  opposite  side, 
or  through  an  opening  which  it  has  itself  effected,  or  that 
has  been  formed  by  art  for  its  escape.  Also  the  traversing 
of  the  ulcer  from  the  interior  through  the  bony  walls  of  the 
cavity  and  external  soft  parts.  An  opening  of  this  sort  may 
be  effected  through  the  cheek,  near,  or  even  into,  the  orbit, 
which  last  has  often  happened  ;  at  other  times,  it  is  effected 
through  the  canine  fossa  or  palatine  arch.  Moreover,  the 
matter  escaping  from  the  sinus,  often  has  flocculi  mixed  with 
it,  which  is  never  the  case  in  simple  muco-purulent  secretion 
of  the  sinus.  These  flocculi  sometimes  choke  up  the  natural 
opening  of  the  cavity  and  cause  its  secretions,  together  with 
those  of  the  ulcers,  to  accumulate,  and  distend  its  osseous 
walls  until  they  ultimately  give  way,  or  an  opening  is  formed 
for  their  escape.  It  occasionally  happens  that  the  flocculi 
lodged  in  the  nasal  opening,  suddenly  give  way,  and  permit 
the  matter  to  pass  into  the  nose. 

When  the  ulcer  is  of  a  fungous  character,  the  matter  se- 
creted is  thin,  of  a  dark  brown  or  blackish  color,  and  has 
mixed  with  it  blood  and  pus.*  It  is,  says  Deschamps, 
slightly  painful,  and  can  only  be  distinguished  Irom  other 
ulcers  by  the  introduction  of  the  bougie  into  the  sinus  ;  and 
like  polypus,  it  is  capable  of  spreading  and  penetrating 
every  opening  that  will  give  it  passage  ;  but,  in  consequence 

*  Maladies  des  Fosses  Nazales,  sec.  2,  art.  vi,  p.  .263. 


I 


I 
I 


CAUSES   OF   ULCEKATION.  601 

of  its  being  of  a  softer  consistence,  it  makes  less  impression 
upon  the  surrounding  parts. 

If  the  ulcer  be  of  a  cancerous  nature,  the  pain  will  be 
sharp  and  lancinating,  affecting  the  whole  of  the  side  of  the 
face  ;  the  matter  will  be  serous,  very  fetid,  and  streaked 
with  blood.  If  discharged  through  the  natural  opening 
into  the  nose,  it  will  cause  the  pituitary  membrane  of  the 
nasal  cavity  of  the  affected  side  to  become  exceedingly  irri- 
table, sensitve  to  the  touch,  and  to  ulcerate.  The  bones  of 
the  affected  side  of  the  face  soon  become  softened  or  carious, 
the  teeth  loosen,  the  external  soft  parts  inflame  and  ultimately 
ulcerate  ;  openings  are  formed  into  the  sinus,  fever  of  a  low 
grade  supervenes,  and  ultimate  death  closes  the  scene. 

CAUSES. 

A  degenerated  or  altered  state  of  the  secretions  of  this 
cavity,  is  said  to  be  the  most  common  cause  of  ulcers  in  it.* 
This  may  be  an  exciting  cause,  and  it  may  be  one  of  the 
most  frequent  exciting  causes,  but  were  it  not  favored  by 
constitutional  predisposition,  it  would  seldom  give  rise  to 
them.  Local  irritation,  whether  produced  by  an  altered 
condition  of  its  secretions,  or  by  the  presence  of  decayed  or 
dead  teeth,  the  roots  of  teeth,  or  a  blow  upon  the  cheek, 
may  be,  and  doubtless  is,  the  exciting  cause  of  ulcers  in  the 
mucous  membrane  of  this  cavity.  This,  however,  in  a  sub- 
ject of  good  constitutional  health,  would  have  to  be  very 
severe  and  continue  for  a  long  time,  to  occasion  ulceration, 
and  even  then,  a  cure  would  soon  be  effected  by  the  restora- 
tive powers  of  the  economy.  It  is  only  in  bad  habits  or  de- 
bilitated constitutions,  that  malignant  ulcers  are  met  with 
in  the  maxillary  sinus. 

Deschamps,  although  he  acknowledges  that  diseased  teeth 
often  exercise  a  morbid  influence  upon  this  cavity,  and  that 
the  apices  of  the  roots  of  these  organs  are  sometimes  in  con- 

*  Maladies  des  Fosses  Nazales,  see.  2,  art.  vi,  p.  159. 

39 


602  TREATMENT   OF   ULCERATION. 

tact  with  its  mucous  or  lining  membrane,  seems  nevertheless 
to  doubt  that  they  have  any  agency  in  the  production  of 
ulcers.  His  reasoning  upon  the  subject  is  far  from  satisfac- 
tory. While  he  admits  that  by  the  contact  and  adhesion  of 
the  dental  periosteum  and  mucous  membrane  of  the  antrum, 
and  the  penetration  of  its  floor  by  the  roots  of  teeth,  in- 
flammation and  ulceration  may  be  produced,  he  denies  that 
it  can  be  positively  proven.  Although  we  may  not  be  able 
to  adduce  positive  evidence,  the  circumstantial  proofs  which 
we  have,  are  so  clear  and  strong,  that  no  candid  inquirer 
can,  for  a  single  moment,  doubt  that  the  disease  in  question, 
when  favored  by  a  bad  habit  of  body,  often  results  from 
dental  or  alveolar  irritation.  In  reply  to  the  question  which 
he  a  little  further  on  propounds,  "How  can  the  extraction 
of  a  tooth  be  of  service  in  the  subduction  of  inflammation 
of  the  mucous  membrane  with  which  the  dental  periosteum 
is  only  simply  in  contact?"*  we  answer,  by  this  oj^eration, 
a  constant  source  of  irritation  may  be,  and  often  is,  removed. 
Ulcers  having  absolutely  formed,  a  cure  cannot  always  be 
effected  b}^  the  removal  simply  of  the  exciting  cause. 

TREATMENT. 

As  in  the  case  of  mucous  engorgement^  the  first  indica- 
tion of  cure  is  to  give  egress  to  the  purulent  matter,  and  in 
this,  as  in  the  other  affections,  the  opening  should  be  formed 
at  the  most  dependent  part  of  the  sinus  ;  and  this  should 
be  effected  in  the  manner  as  before  described,  through  the 
alveolar  border,  or  rather  alveolus  of  a  molar  tooth.  It 
should  be  made  large  enough  to  admit  the  little  finger,  and 
if  tlierc  be  any  teeth  so  much  affected  as  to  be  productive  of 
irritation  to  the  parts  subjacent  to  the  antrum,  they  should 
be  removed. 

Free  egress  for  the  matter  having  been  obtained,  and  all 
local  irritants  removed,  the  antrum  should  be  injected  from 

*  Maladies  des  Fosses  Nazales,  sec.  2,  art.  vi,  p.  259. 


TREATMENT  OF  ULCERATION.  603 

time  to  time,  with  gently  stimulating  and  detersive  fluids. 
This,  in  cases  of  simjjle  ulcer,  if  the  constitutional  health  is 
not  seriously  impaired,  will  often  he  all  that  is  required  to 
effect  a  cure. 

If  the  ulcer  is  of  a  fungous  nature,  the  employment  of 
escharotics,  and  sometimes  even  the  actual  cautery  becomes 
necessary  ;  this  last  should  be  repeated  until  the  fungi  are 
completely  destroyed.  With  regard,  however,  to  the  em- 
ployment of  escharotics,  such  as  the  nitrate  of  silver,  sul- 
phate of  copper,  etc.,  for  the  purpose  of  destroying  luxuriant 
granulations  in  ulcers.  Sir  E.  Home  is  of  the  opinion  it  is 
better  to  combine  them  with  some  other  substance,  so  as  to 
prevent  them  from  immediately  destroying  the  granula- 
tions. He  believes  when  this  is  done,  the  surface  of  the 
ulcer,  underneath,  is  more  liable  to  reproduce  them,  than 
when  they  are  removed  by  absorption,  and  it  is  for  this 
reason  he  prefers^  in  the  employment  of  caustics,  to  mix 
them  witli  other  substances,  so  that  they  shall  only  ex- 
ercise a  strong  stimulating  effect,  and  thus  cause  the  gran- 
ulations to  be  gradually  removed  by  the  action  of  the  ab- 
sorbents. 

The  surface  of  the  ulcer  should,  if  practicable,  be  kept 
clean  by  means  of  dossils  of  dry  lint  or  pledgets  spread  with 
some  simple  ointment.  The  treatment  of  ulcers  of  this 
cavity,  is  usually  attended  with  more  difficulty,  on  account 
of  their  concealed  situation,  than  those  of  most  other  parts 
of  the  body.  Among  other  things,  Deschamps  recommends 
injections  of  a  decoction  of  quinine.  In  many  cases  a  lotion 
of  sulphate  of  zinc  may  be  used  with  advantage.  The  rem- 
edies to  be  employed  in  the  treatment  of  ulcers  of  the  max- 
illary sinus,  as  in  the  treatment  of  ulcers  of  other  parts, 
should  be  varied  to  suit  the  indications  of  each  particular 
case.  In  debilitated  subjects,,  tonics,  as  quinine  and  prepa- 
rations of  steel,  are  often  serviceable.  Tliere  are  some  cases 
in  which  mercurials  are  beneficial.  Strict  attention  should 
always  be  paid  to  the  regimen  of  the  patient,  and  such  gen- 
eral treatment  adopted  as  may  be  best  calculated  to  restore 


604  TREATMENT  OF  ULCERATION. 

the  constitutional  health,  for  upon  this,  the  cure  of  the  local 
aflfection  often  depends. 

If  the  ulcer  is  of  an  irritahle  nature,  warm  fomentations, 
(conveyed  to  the  interior  of  the  antrum  hy  means  of  a  pro- 
perly constructed  funnel,)  of  a  decoction  of  poppy  heads, 
chamomile  flowers,  or  the  leaves  of  hemlock,  will  often 
prove  heneficial  in  soothing  the  pain.  Tincture  of  myrrh, 
diluted,  or  a  decoction  of  walnut  leaves  may  be  advantage- 
ously employed  as  injections  in  cases  of  indolent  ulcers — the 
last  of  which  is  recommended  as  an  application  to  ulcers  of 
this  character,  in  other  parts  of  the  body,  by  Hunezawsky, 
and  both  of  which  are  favorably  spoken  of  by  Sir  E.  Home. 
This  last  named  writer  recommends  "diluted  sulphuric 
:acid  and  the  juice  of  the  powder  of  different  species  of  pep- 
■per  in  a  recent  state  ;"  also  nitrous  acid  diluted  with  water. 
'The  unguentum  hydrargyri  nitrate,  mixed  with  lard,  the 
•ceratum  resinee,  and  the  unguentum  elemi,  mixed  with  the 
balsam  of  turpentine,  are  also  recommended.  The  applica- 
tion of  ointment  to  ulcers  of  this  cavity  can  rarely  be  made. 

Many  of  the  ulcers  of  the  maxillary  sinus  are  regarded  as 
incurable,  as  for  example,  such  as  are  of  a  cancerous  nature 
and  ulcerated  fungous  hematodes.  Although  the  resources 
of  surgery  have  hitherto,  in  most  instances,  proved  inade- 
quate to  the  cure  of  these  formidable  diseases,  nevertheless, 
they  should  be  put  in  requisition,  and  we  should  endeavor 
to  combat  them  by  every  means  in  our  power.  Deschamps 
says^  the  interior  of  the  antrum  should  be  exposed  at  the 
commencement  of  the  disease.  He  recommends  the  forma- 
tion of  a  large  opening,  if  the  alveolar  ridge  be  healthy, 
above  it,  if  not,  through  it,  exposing  as  much  of  the 
cavity  as  possible.  This  done,  he  directs,  if  there  is  a 
cancerous  tumor,  that  it  be  as  thoroughly  extirprted,  by 
means  of  a  curved  and  flat  bistoury  or  curved  scissors,  as 
possible.  All  that  may  have  escaped  removal  by  this  means, 
he  says^  should  be  touclied  with  the  actual  cautery.  These 
are  the  only  remedies  to  be  employed  when  the  membrane 
is  in  a  state  of  cancerous  ulceration.     The  surgeon  should 


TREATMENT  OF   ULCERATION.  605 

destroy  the  parts  in  such  a  way  as  to  leave  only  the  osseous 
surfaces,  and  he  should  pay  some  attention  to  these  bony 
parts,  which,  also,  he  should  carefully  cauterize.  The  dis- 
ease having  been  thus  removed,  the  surrounding  osseous 
walls  which  have  been  cauterized  will  soon  exfoliate,  when 
a  cliance  for  a  cure  will  be  afforded,  and  of  which,  if  the 
neighboring  parts  have  not  been  too  extensively  invaded, 
nature  will  avail  herself.  The  administration  of  soothing 
and  anodyne  medicines  are  also  directed.  Arsenic  has  been 
employed  with  advantage  as  an  external  remedy  in  ulcers 
of  this  kind. 

The  following  case  of  fungous  ulcer,  complicated  with 
alteration  of  the  walls  of  the  sinus_,  is  taken  from  Bor- 
deuave's  collection  of  observations  on  the  diseases  of  tliis 
cavity,  in  the  Memoirs  of  the  Royal  Academy  of  Surgery, 
Although  the  history  of  the  case,  in  its  translation,  is  some- 
what abridged,  yet  no  important  fact  connected  with  it  is 
omitted. 

Case  12th.  The  subject  of  this  case  was  a  woman  twenty- 
six  years  of  age  ;  wlio  having  exposed  herself,  while  in  a 
critical  state  of  health,  to  cold  air,  was,  in  1759,  attacked 
with  acute  pains  in  the  left  side  of  her  upper  jaw  ;  in  the 
alveolar  ridge  of  wliich  were  the  roots  of  several  decayed 
teeth.  The  following  day  her  jaw  was  swollen,  and  although 
the  pain  ceased  in  a  few  days,  the  swelling  continued,  with- 
out any  change  in  the  appearance  of  the  skin  ;  nevertheless, 
her  face  was  deformed  in  shape.  The  orbitary  apophysis  of 
the  maxillary  bone  became  elevated,  and  the  substance  of 
the  bone  softened.  The  interior  of  the  nose  was  affected 
and  tlie  opening  of  the  sinus  into  this  cavity  was  closed. 
The  matter  collected  in  the  antrum  began  to  escape,  twenty- 
two  days  after  tlie  attack,  through  the  alveoli. 

In  January,  1761,  the  symptoms  becoming  more  aggra- 
vated, she  went  to  Paris  for  medical  aid.  M.  Beaupreau 
was  consulted,  and  on  examining  the  affected  parts,  deter- 
mined on  the  extraction  of  the  decayed  teeth,  wliich  were 
considerably  broken.     They,  however,  adhered  so  firmly  to 


606  TREATMENT  OF  ULCERATION. 

the  alveolar  cavities  that  he  could  not  move  them  without 
shaking  their  sockets.  This  deterred  him  from  proceeding 
with  the  operation  as  he  had  begun,  and  he  resolved  to  re- 
move the  whole  of  the  alveolar  border  with  a  bistoury,  from 
the  lateral  incisor  to  the  first  molar,  and  in  this  way  remove 
the  teeth  with  the  bone.  This  done,  he  made  a  section  of 
the  bone^  which  had  become  softened,  with  a  pair  of  scissors, 
in  the  direction  of  the  cuspidatus.  The  antrum  was  much 
dilated  ;  its  membiane  fungous  and  ulcerated.  He  then 
treated  it  with  .detersive  injections,  adhesive  dossils,  covered 
with  digestives,  composed  of  the  oil  of  turpentine.  In  ad- 
dition to  these,  mercurial  ointment  and  red  precipitate  were 
used.  Alterative  pills,  and  beverages  clarified  with  cress, 
were  also  prescribed  ;  this  treatment  was  successful,  for, 
five  days  after  it  had  been  commenced,  the  tumor  had  per- 
ceptibly diminished,  the  pus  became  of  a  better  quality  and 
less  in  quantity.  At  the  expiration  of  two  months,  the  dis- 
charge became  mucous.  Injections  of  lime  water,  at  first 
strong,  and  afterwards  milder,  were  used.  The  natural 
opening  was  closed,  and  continuing  impervious,  an  opening 
through  the  base  of  the  sinus  was  preserved.  At  the  ex- 
piration of  two  months,  the  parts  had  recovered,  and  the 
general  health  of  the  patient  was  restored. 

The  medical  treatment  in  the  foregoing  case  was  very 
proper  ;  it  accorded  with  the  curative  indications  of  the  dis- 
ease, but  the  surgical  evidently  involved  a  greater  sacrifice 
of  substance  than  was  absolutely  called  for.  The  extraction 
of  teeth  was  not,  however,  as  well  understood  at  that  time  as 
at  present,  and  it  was  to  the  want  of  proper  knowledge  and 
skill  in  this  department  of  surgery,  that  the  removal  of  so 
considerable  a  portion  of  the  alveolar  ridge  was  had  recourse 
to.  It  is  often  necessary  to  make  a  very  large  opening  into 
the  sinus,  but  it  is  seldom  requisite  to  make  one  as  large  as 
that  made  in  this  instance ;  altliough  nearly  the  same  treat- 
ment was  adopted  in  a  case  of  a  somewhat  similar  nature 
by  Bourdet,  the  practice  is  nevertheless  objectionable.  When 
the  subjacent   bone  and  alveolar  border  are  in  a  carious  or 


TREATMENT   OF   ULCERATION.  607 

necrosed  state,  their  removal  would  be  proper,  and  there 
are  diseases  that  occur  in  this  cavity  which  render  the  ope- 
ration necessary,  but  in  neither  of  the  cases  just  noticed^ 
were  the  bones  so  carious,  nor  was  the  nature  of  the  disease 
such  as  to  require  so  large  an  opening.  In  the  first  case, 
the  outer  wall  of  the  sinus,  as  would  seem  from  the  descrip- 
tion given,  was  softened,  but  in  the  other,  Bourdet  says  the 
bones  were  not  diseased. 

It  sometimes  happens  when  the  opening  through  the  al- 
veolar border  is  very  large,  it  never  closes^  and  when  the 
natural  opening  becomes  obliterated,  it  is  requisite  to  pre- 
serve an  artificial  one  ;  in  either  of  these  cases  the  employ- 
ment of  an  obturator  is  necessary  to  prevent  particles  of 
food  and  extraneous  matter  from  getting  into  the  sinus.  Of 
these  we  shall  hereafter  speak. 

The  history  of  many  highly  interesting  cases  of  ulcera- 
tion of  the  mucous  membrane  of  this  cavity^  might  be  intro- 
duced, but  as  tliis  form  of  diseased  action  is  so  often  com- 
plicated with  caries,  necrosis,  and  other  alterations  of  its 
osseous  walls,  we  have  thought  it  would  be  as  well  to  reserve 
them  until  we  treat  of  those  aifections  ;  which  we  shall  now 
proceed  to  do. 


CHAPTER      SIXTH. 

CARIES,    NECROSIS    AND    SOFTENING    OF    THE    BONY 
PARIETES  OF  THE  MAXILLARY  SINUS. 

The  osseous  walls  of  the  antrum,  and  sometimes  the 
whole  of  the  subjacent  alveolar  border,  and  that  of  the  su- 
perior maxillary,  the  nasal,  palatine  and  orbital  bones,  as 
well  as  some  that  belong  to  the  base  of  the  cranium  and  the 
malar  bone,  are  involved  in  caries  or  necrosis.  Mollities 
ossium,  though  rarely  occurring  in  the  alveolar  ridge,  fre- 
quently affects  the  walls  of  the  sinus.  Caries  may  affect  a 
considerable  portion  of  both  for  a  long  time,  without  com- 
pletely destroying  the  vitality  of  the  diseased  parts. 
During  its  continuance  fetid  sanies  is  discharged  from  one 
or  more  fistulous  openings  through  some  part  of  the  cheek, 
alveoli,  gums,  palatine  arch,  or  into  the  sinus,  and  from 
thence  through  the  natural  opening  into  the  nose.  The 
disease  eventually  terminates  in  the  decomposition  and  death 
of  the  parts  affected,  and  then  by  an  operation  of  the 
economy,  they  are  separated  from  the  living  bone  and 
thrown  off,  or  in  other  words,  exfoliated.  Although  caries 
ultimately  causes  the  death  of  the  bone  affected  by  it,  it  does 
not  always  precede  the  destruction  of  vitality.  The  occur- 
rence of  necrosis,  therefore,  although  it  may  result  as  aeon- 
sequence  of  caries,  is  not  necessarily  dependent  upon  it. 

When  the  parietes  of  the  antrum  or  alveoli  are  affected 
by  necrosis,  the  soft  parts  in  contact  with  the  diseased  or 
dead  bone,  inflame,  ulcerate  and  discharge  fetid  ichorous 
matter.  The  gums  sometimes  become  gangrenous  and 
slough.     The  destruction  of  the  vitality  of  the  osseous  parts 


SYMPTOMS   OF   CARIES   AND   NECROSIS   OF    THE   W  .LLS.       609 

often  progresses  very  slowly,  and  thus,  piece  after  piece,  is 
exfoliated,  until  the  disease  is  arrested. 

Besides  these  affections,,  it  not  unfrequently  happens  that 
the  osseous  jDarietes  of  this  cavity  are  so  softened  as  to  be 
easily  bent.  This  alteration  of  the  bone,  as  well  as  the 
others  just  noticed,  are,  in  nearly  every  instance,  preceded 
by  some  other  form  of  disease. 

The  annoyance  occasioned  by  caries  and  necrosis  of  the 
bony  walls  of  this  cavity  or  of  the  alveoli,  to  the  unhappy 
patient,  is  very  great.  The  fetor  of  the  sanies  is  sometimes 
almost  insufferable ;  the  matter  often  excoriates  and  inflames 
the  parts  with  which  it  comes  in  contact  to  such  a  degree, 
as  to  cause  them  to  become  exceedingly  sensitive  and  not 
unfrequently  to  ulcerate. 


SYMPTOMS. 

It  is  sometimes  difficult  to  distinguish  caries  and  necrosis 
of  the  bony  parietes  of  the  antrum  from  some  of  the  other 
diseases  of  this  cavity.  They,  therefore,  often  exist  for  a 
long  time  without  being  suspected.  The  signs  that  indicate 
moUities  ossium,  or  softening  of  the  walls,  are  such  as  not  to 
be  easily  mistaken  for  those  of  any  other  affection.  In  this 
disease,  the  walls  of  the  sinus  yield  to  pressure,  and  regain 
their  former  shape  when  the  pressure  is  removed.  Its  ex- 
istence, therefore,  may  always  be  known  by  these  signs,  and 
as  these  are  sufficient,  it  is  not  necessary  to  enumerate  any 
others  by  which  it  is  characterized.  Caries  and  necrosis  not 
being  so  easily  detected,  often  make  considerable  progress 
before  their  existence  is  ascertained.  The  fetor  and  appear- 
ance of  the  matter  discharged  do  not  always  furnish  a  diag- 
nosis that  can  be  relied  upon,  inasmuch  as  some  of  the  dis- 
eases that  occur  here  cause  its  secretions  to  become  equally 
as  offensive  as  the  sanies  resulting  from  caries  or  necrosis, 
and  not  unlike  it  in  a])pcarance.  Their  existence  may  in 
most   instances    be  inferred,  from  the  discharge  of  dar^-- 


t 


610  CAUSE   OF   CARIES   AND   NECROSIS   OF   THE  WALLS. 

colored  fetid  sanies.  The  exfoliation  of  pieces  of  bone  will 
set  all  doubt  at  rest. 

Caries  or  necrosis  may  often  be  detected  by  perforating 
the  antrum  and  exposing  the  denuded  or  diseased  bone ;  or 
when  there  is  an  external  opening,  by  probing  it.  In  this 
way  any  loose  or  dead  bone  may  be  felt  with  the  instru- 
ment; and  the  diagnosis  in  either  case  will  be  satisfactory. 

Wlien  caries  or  necrosis  is  situated  in  the  alveolar  border, 
or  floor  of  the  antrum,  its  existence  can  be  more  readily  as- 
certained. The  occurrence  of  either  in  the  alveolar  ridge, 
causes  the  gums  to  inflame  ;  to  assume  a  dark  purple  or 
livid  appearance  ;  to  separate  from  the  sockets  of  the  teeth, 
and  frequently  to  slough  in  large  pieces  and  expose  the 
caried  or  necrosed  bone.  When  situated  in  the  floor  of  the 
antrum,  the  rough  denuded  bone  may  be  easily  felt  with  a 
probe  or  stilet,  introduced  through  the  fistula  in  the  gums 
or  tlie  alveolus  from  which  the  matter  is  discharged. 

The  pain  accompanying  these  affections  does  not  consti- 
tute a  diagnosis  of  much  importance,  since  this  does  not  be- 
long to  the  osseous  tissue,  but  to  the  soft  parts  that  cover  it. 


CAUSES. 

The  immediate  cause  of  caries  and  necrosis  of  the  osseous 
walls  of  ihe  antrum  maxillare  is  suppurative  inflammation, 
or  the  destruction  of  their  periosteum ;  which  may  result 
from  a  purulent  condition  of  the  secretions  of  the  mucous 
membrane,  engorgement,  tumors,  a  blow  upon  the  cheek  or 
from  other  kinds  of  mechanical  violence.  They  may  also 
arise  fron)  the  irritation  produced  by  diseased  teeth.*  The 
pressure  of  incarcerated  fluids,  may,  perhaps,  be  regarded 
as  the  most  frequent  cause  ;  and  from  this,  too,  results  some 

*  Fouchard  says,  he  saw,  in  the  Anatomical  Museum  of  the  University  of  Copen- 
hagen, caries  of  the  bones  of  the  face,  produced  by  a  molar  tooth,  the  crown  of 
which,  having  turned  outwards,  had  penetrated  the  maxillary  sinus.  3Iem.  de 
V  Academie  de  Chirurg.,  vol.  v,  mem.  257. 


TREATMENT   OF   CARIES   AND    NECROSIS   OF   THB  WALLS.      611 

of  tlie  most  aggravated  forms  of  disease  that  ever  attack 
this  cavity. 

A  morbid  action  kept  up  in  the  periosteum  for  a  long 
time,  by  ulceration  of  the  lining  membrane,  or  any  other 
aggravated  form  of  disease  in  the  sinus,  or  neighboring  soft 
parts,  is  apt  to  give  rise  to  caries  of  the  bone,  but  when 
the  inflammation  is  so  severe  as  to  cause  the  immediate 
destruction  of  the  periosteal  tissue,  necrosis  at  once  takes 
place. 

The  softening  of  the  bone,  seems  to  be  the  result  of  the 
action  of  some  solvent  fluid  upon  it,  capable  of  decomposing 
or  breaking  down  its  calcareous  molecules.  Although  in- 
flammation and  ulceration  are  always  present,  and  appear 
necessary  to  the  exudation  of  this  fluid,  its  production, 
nevertheless,  seems  to  be  dependent  upon  some  peculiar 
state  or  habit  of  body. 

TREATMENT. 


Complicated,  as  are  most  frequently^  caries,  necrosis  and 
other  alterations  of  the  osseous  walls  of  the  maxillary  sinus, 
with- other  affections  of  this  cavity,  their  cure  is  often  diffi- 
cult and  generally  tedious.  The  first  indication  to  be  ful- 
filled, however,  in  their  treatment,  as  in  the  case  of  en- 
gorgement, and  of  a  muco-purulent  condition  of  the  secre- 
tions, is  to  obtain  free  egress  for  any  fluids  which  may  have 
accumulated  lierc.  This  may  be  effected  in  the  manner  as 
before  described.  In  addition  to  this,  if  the  disease  of  the 
osseous  tissue  is  complicated  with  any  other  affection  of  the 
sinus,  such  means  as  are  necessary  for  the  cure  of  the  disease 
with  which  it  is  complicated,  should  at  once  be  em])loyed. 
It  is  not  necessary  here  to  describe  the  treatment  of  the  other 
diseases  of  this  cavity,  as  tliat  lias  already  or  will  hereafter 
be  done. 

Deschamps,    in    treating   upon   these   aff'ectionS;,   recom- 
mends the  employment  of  detersive  and  stimulating  injec- 


612      TREATMENT   OF  CARIES  AND  NECROSIS  OF  THE  WALLS, 

tions,  a  decoction  of  quinine,  tinct.  of  myrrli  and  aloes,  &c. 
These  last,  he  says,  may  be  introduced  as  injections,  or  by 
means  of  pledgets  moistened  in  them.  He  also  directs  the 
cavity  to  be  "cleared  of  all  foreign  matter  which  ma)'  have 
obtained  admission  into  it."  This  treatment,  having  a  ten- 
dency to  promote  a  healthy  action  in  the  lining  membrane, 
will  often  be  all  that  is  required.  It  should  be  continued 
until  the  caried  or  necrosed  bone  has  exfoliated,  and  the 
secretions  of  the  antrum  cease  to  exhale  an  offensive  odor. 
The  dead  bone,  however,  having  exfoliated,  a  cure  is  gene- 
rally soon  effected. 

It  sometimes  happens  that  the  disease  of  the  bone  has 
been  produced  by  some  very  malignant  and  incurable  affec- 
tion of  the  soft  parts.  In  this  case,  tlie  resources  of  art 
will,  of  course,  prove  unavailing.  When  the  disease  of 
the  bone  has  extended  itself  to  the  greater  part  of  the  supe- 
rior maxillary  and  the  bones  with  which  it  is  connected,  as, 
for  example,  the  nasal,  palatine,  orbital,  &c.,  the  most  that 
can  be  hoped  for,  from  the  skill  of  the  physician,  is  a 
palliation  of  the  symptoms.  Art,  in  such  cases,  can  sel- 
dom effect  a  cure.  There  are  other  cases  in  which  it  can 
only  retard  the  progress  of  the  disease,  or  assist  nature  in 
her  efforts  to  separate  the  dead  from  the  living  bone. 

It  is  impossible  to  lay  down  rules  for  tlie  treatment  of  al- 
terations of  the  walls  of  the  maxillary  sinus,  from  which  it 
will  not  be  necessary  occasionally  to  deviate.  It  will  be  suf- 
ficient to  state,  that  in  those  cases,  where  they  are  exten- 
sively involved  in  caries  or  necrosis,  it  will  be  proper,  in 
addition  to  perforating  the  base  of  the  sinus,  if  by  this 
means  the  dead  bone  cannot  be  so  exposed  as  to  enable  the 
surgeon  to  detach  it  from  the  living,  to  cat  away  the  whole 
of  the  alveolar  border  beneath  the  cavity,  or  to  penetrate 
the  sinus  above  it,  or  even,  as  Deschamps  recommends, 
''through  the  cheek  itself,  whether  there  be  an  ulcer  pene- 
trating these  parts  or  not."  Having,  by  this  means,  ex- 
posed the  necrosed  bone,  it  should  be  carefully  detached 
from  the  sound  and  removed. 


\ 


TREATMENT   OF   CARIES   AND   NECROSIS   OF   THE   WALLS.     613 

The  character  which  the  affections  of  this  cavity  put  on, 
being  determined  by  tlie  state  of  the  constitutional  health, 
or  some  particular  vice  of  body,  it  often  becomes  necessary 
in  their  treatment,  to  have  recourse  to  general  remedies.  If 
the  subject  is  of  a  scrofulous  or  scorbutic  habit,  or  is  affected 
with  any  specific  constitutional  vice,  such  remedies  as  are 
indicated  by  tlie  affection  of  the  general  system  should  be 
employed. 

Although  tlie  character  and  malignancy  of  the  disease  are 
determined  by  the  state  of  the  constitutional  health,  or  dis- 
position of  body,  its  occurrence  seems  to  be  dependent  upon 
local  irritation.  Its  continuance,  in  many  instances,  results 
from  this  ;  and  the  cure,  in  cases  of  this  kind,  soon  follows 
the  removal  of  the  cause  that  gave  rise  to  it.  In  a  case,  the 
history  of  which  we  are  now  about  to  detail,  an  example  of 
this  sort  is  furnished. 

Case  13th.   L.  S ,  a  maiden  lady  of  about  thirty  years 

of  age,  of  a  scorbutic  habit,  had  been  affected  with  pain  in 
her  left  cheek  and  alveolar  ridge  for  nearly  two  years  ;  which 
at  times  had  been  almost  insupportable.  Nearly  all  her 
teeth  were  affected  with  caries,  and  from  between  the  necks 
of  several,  on  the  left  side  in  the  superior  maxillary  and 
gums,  fetid  sanies  had  been  exuding  for  two  or  three  months. 
Her  appetite  had  become  greatly  impaired,  and  a  tumor  half 
the  size  of  a  black  walnut,  having  formed  upon  the  palatine 
arch  of  the  affected  side,  she  became  alarmed,  and  in  the 
fall  of  1840,  came  from  her  residence  on  the  Eastern  Shore 
of  Maryland,  to  Baltimore,  in  pursuit  of  medical  aid.  She 
applied  to  Professor  T.  E.  Bond,  who,  after  investigating 
the  case,  and  satisfying  himself  that  the  affection  was  the 
result  of  the  diseased  condition  of  her  teeth,  advised  her  to 
place  herself  under  our  care,  which  she  did  on  the  follow- 
ing day. 

The  sockets  of  four  of  the  teeth  of  the  affected  side,  in 
the  superior  maxillary,  were,  on  examination,  found  to  be  in 
a  necrosed  condition,  as  was  also  a  part  of  the  palatine  bone 
of  the  same  side.     The  gums  around  these  teeth  had  sepa- 


614      TREATMENT   OF    CARIES   AND    NECROSIS   OF   THE   WALLS. 

rated  from  the  alveolar  processes,  and  had  a  dark  livid  ap- 
pearance. A  thin  dark  colored,  ichorous  matter,  which, 
when  brought  in  contact  with  silver_,  almost  instantly  turned 
it  black,  was  constantly  exuding  from  between  them  and  the 
necks  of  the  teeth.  The  left  nostril  was  dry,  and  tlie  open- 
ing from  the  sinus  had  evidently  closed.  Exceedingly  fetid 
matter  had  been  discharged  from  it  during  the  early  stages 
of  the  disease.  The  tumor  on  the  left  side  of  the  arch  of 
the  palate  was  soft  and  elastic.  When  pressed,  dark  colored 
sanies  was  discharged  from  the  alveoli,  and  it  then,  for  a 
time,  disappeared. 

The  alveolar  processes  being  in  a  necrosed  and  loose  con- 
dition, it  was  with  some  difficulty  we  succeeded  in  removing 
the  bicuspids,  and  the  first  and  second  superior  molars  of 
the  left  side,  without  bringing  their  sockets  with  them. 
The  operation  was  followed  by  a  discharge  of  a  considerable 
quantity  of  fetid  sanies  ;  and,  in  a  few  days,  the  alveoli 
having  become  completely  detached  from  the  sound  bone, 
we  removed  them,  together  with  a  part  of  the  floor  of  the 
antrum.  The  opening  thus  formed  into  the  sinus  was 
large  enough  to  admit  the  end  of  the  fore-finger.  Several 
small  pieces  of  bone  were  afterwards  exfoliated,  from  where 
the  teeth  had  been  extracted,  and  three  pieces  from  the  left 
side  of  the  palatine  arch. 

Without  any  other  treatment,  the  place  from  which  the 
teeth  and  alveoli  had  been  removed,  except  the  opening  that 
communicated  with  the  maxillary  sinus,  had  in  about  seven 
weeks,  become  entirely  covered  with  firm  and  healthy  granu- 
lations. From  the  opening  into  the  antrum,  fetid  matter 
was  still  discharged.  This  became  less  and  less  offensive, 
until  at  the  expiration  of  six  or  eight  weeks,  the  opening 
into  the  nose  having  become  re-established,  it  lost  its  fetid 
odor,  and  the  aperture  at  the  base  of  the  sinus  soon  after 
closed. 

Thus,  in  a  little  more  than  three  months,  a  complete  cure 
was  effected.  The  patient  left  the  city  in  the  following 
spring,  and  we  have  not  since  heard  from  her. 


TREATMENT   OF   CARIES   AND   NECROSIS   OF   THE   WALLS.     615 

The  following  case  is  taken  from  Bordenave's  Observations 
on  the  Diseases  of  the  Antrum  Maxillare,  as  published  in 
the  Memoirs  of  the  Royal  Academy  of  Surgery.  Although 
in  the  translation,  as  here  presented,  it  is  considerably 
abridged,  no  important  fact  connected  with  it  has  been 
omitted.* 

Case  14th.  A  man,  whose  right  superior  maxillary,  at 
the  uj)per  part,  had  been  swollen  for  about  three  months, 
had,  at  the  same  time  a  soft  tumor  on  the  interior  of  the 
palate,  which^  on  being  pressed,  caused  matter  to  be  dis- 
charged from  the  nostril  of  that  side.  These  aifections,  to- 
gether with  tumefaction  of  the  gums,  looseness  of  several 
of  the  teeth,  and  fetid  breath,  induced  M.  Planque,  under 
whose  care  the  patient  was  placed,  to  suspect  suppuration  of 
the  maxillary  sinus,  complicated  with  a  scorbutic  diathesis  of 
the  general  system.  The  molars,  which  only  adhered  to  the 
gums,  having  been  extracted,  matter  was  discharged  through 
their  alveoli.  A  portion  of  the  maxillary  bone  was  now 
discovered  to  be  carious,  and  this,  in  about  a  month,  began 
to  loosen,  and  a  piece  of  about  an  inch  and  a  half  long,  and 
half  an  inch  in  width,  some  time  after  exfoliated.  The 
tumor  exteriorly  disappeared  ;  the  walls  of  the  sinus  approxi- 
mated, and  a  cicatrix  ultimately  closed  the  opening. 

The  details  of  many  similar  cases  are  on  record,  but  it 
would  be  extending  the  limits  of  this  part  of  our  work  too 
far  to  introduce  them  here.  The  history  of  the  cases 
already  given,  will  suffice  to  illustrate  the  treatment  of 
these  affections.  We  would,  however,  have  given  a  case  of 
moUities  ossium  of  the  walls  of  this  cavity,  had  we  not, 
while  treating  of  ulceration  of  the  lining  membrane,  quoted 
one  in  which  that  affection  had  become  comj)licated  with 
this. 

It  sometimes  happens,  when  a  very  large  opening  has 

*  Another  interesting  case  is  narrated  by  Bordenave,  which  the  author  has  given 
in  his  Treatise  on  the  Diseases  of  the  Maxillary  Sinus,  p.  115. 


616     TREATAIENT   OF   CARIES   AND   NECROSIS   OF   THE   WALLS. 

been  formed  througli  fhe  inferior  part  of  this  cavity,  that  it 
does  not  always  readily  close.  It  is  true  this  does  not  often 
occur,  except  the  natural  opening  has  become  obliterated. 
When  the  parts  do  not  manifest  a  disposition  to  unite,  the 
practice  introduced  by  Bordenave  and  Scultet,  which  con- 
sists in  cauterizing  the  interior  circumference  of  the  open- 
ing, will,  in  most  instances,  prove  successful.  If  this  and 
all  other  means  fail,  the  opening  may  be  closed  by  means 
of  an  obturator  of  fine  gold.  This  should  be  accurately 
fitted  to  the  parts,  and  secured,  by  means  of  a  broad  clasp, 
to  a  molar  or  bicuspid  tooth,  and  if  there  be  none  suitable 
on  this  side  of  the  mouth,  to  which  it  can  be  applied,  the 
gold  should  be  extended  to  one  on  the  opposite  side.  If  it 
be  necessary  to  replace  the  lost  teeth  with  artificial  ones, 
these  may  be  so  mounted  that  the  plate  upon  which  they  are 
set,  shall  cover  the  opening  into  the  maxillary  sinus,  and 
thus  obviate  the  necessity  of  any  other  obturator. 


CHAPTER     SE TENTH. 

TUMORS  OF  THE  LINING  MEMBRANE  AND  PERIOSTEUM 
OF  THE  MAXILLARY   SINUS. 

The  lining  membrane  and  periosteal  tissue  of  the  maxil- 
lary sinus  occasionally  become  the  seat  of  fungous  and  other 
tumors,  and  in  consequence  of  the  concealed  situation  of  the 
cavity,  morbid  productions  originating  in  it,  often  make 
considerable  progress  before  they  attract  attention;  hence, 
the  efforts  of  art  for  their  cure,  which  might  otherwise  fre- 
quently be  successful,  in  most  instances  prove  unavailing. 
The  presence  of  a  tumor  may  give  rise  to  all  the  diseases  to 
which  its  osseous  walls  are  liable,  as  well  as  to  most  of 
those  incident  to  its  soft  tissues.  As  soon  as  the  morbid 
growth  has  filled  the  sinus,  it  presses  upon  the  lining  mem- 
brane, excites  inflammation,  and  sometimes  ulceration^ 
causing  its  secretions  to  become  vitiated.  A  diseased  action 
is  communicated  to  the  periosteum  of  the  surrounding  osse- 
ous walls,  this  ceases  to  furnish  the  hard  tissues,  with  the 
healthy  juices  which  they  require  for  their  preservation  ;  the 
periosteum  thickens,  ulcerates,  and  is  destroyed,  or  exudes 
a  corrosive  fluid.  The  bony  parietes  are  softened  or  become 
affected  with  caries  or  necrosis,  and  one  or  more  fistulous 
openings  are  formed  through  the  cheek,  alveoli,  or  palatine 
arch. 

These  are  not  the  only  effects  that  result  from  tumors 
situated  in  this  cavity.  As  they  increase  in  volume, 
after  having  filled  the  antrum^  they  gradually  distend 
and  displace  its  bony  walls  ;  the  floor  of  the  orbit  is 
sometimes  elevated,  and  the  eye  more  or  less  forced  from  its 
socket;  the  palatine  arch  and  alveolar  ridge  are  depressed, 
the  teeth  loosen  and  drop  out.  When  the  tumor  is  of  a 
40 


618  TUMORS   OF    LIXIXG   MEMBRANE   AND   PERIOSTEUM. 

soft  fungous  nature,  it  not  unfrequently  escapes  through 
the  alveoli  into  the  mouth,  and  after  forcing  the  jaws  asun- 
der to  their  greatest  extent,  protrudes  from  it  in  enormous 
masses.  Bertrandi  gives  the  history  of  a  case  of  a  polypus 
excrescence  of  the  antrum,  which,  after  having  destroyed 
the  paUite,  anterior  part  of  the  maxillary  bone,  and  filled 
the  mouth,  forced  itself  up  into  the  orhit,  elevated  its  roof, 
pressed  upon  the  hiain,  and  ultimately  occasioned  apoplexy 
and  death.  Other  similar  cases  are  on  record.  Mr.  Coop- 
er says  there  are  three  specimens  of  diseased  antrum  in  the 
museum  of  the  London  University  College.  The  tumor  in 
two  of  these  had  ''made  its  way  from  the  antrum  to  the 
brain."  The  third  was  taken  from  a  patient  of  his, 
which  had  died.  The  tumor  in  this  case,  which  was  of  a 
medullary  and  scirrhous  character,  forced  itself  up  into  the 
orbit,  displaced  the  eye,  and,  ultimately,  caused  the  death 
of  the  patient.  The  same  author  mentions  another  case, 
the  subject  of  which  was  a  boy  in  St.  Bartholomew's  Hospi- 
tal, who  had  a  tumor  of  the  antrum,  which  ''made  its  way 
through  the  orbitar  plate  of  the  frontal  bone  and  cribriform 
plate  of  the  ethmoid  into  the  cranium,"  and  though  the 
portion  of  it  that  entered  the  brain  was  as  large  as  a  small 
orange,  he  says  the  boy  was  only  in  a  comatose  state  about 
forty-eight  hours  previously  to  his  death. 

Tumors  occupying  the  maxillary  sinus  donot  always  origi- 
nate in  the  lining  membrane  or  periosteum.  They  some- 
times arise  from  the  pituitary  membrane  of  the  nose,  frontal  si- 
nus, or  ethmoidal  cells,  and  after  having  found  their  way  into 
this  cavity^  augment  in  size,  until  they  produce  the  efiects 
just  described.  Some  suppose  that  the  morbid  productions 
found  here,  originate  more  frequently  in  the  cells  of  the 
etlimoid  bone,  than  in  the  lining  membrane  of  this  cavity.* 

We  are  disposed  to  believe  that  this  opinion  is  not  well 
founded,  and  that  it  has  chiefly  resulted  from  the  great  li- 
ability of    most  kinds  of  tumors  of  this  cavity,   to   be   re- 

*  Vide  Traite  des  Maladies  do  la  Bouch,  t.  i,  p.  210. 


TUMORS   OF   LINING   MEMBRANE   AND   PERIOSTEUM.  619 

produced  after  having  been  extirpated — whicli  is  often  at- 
tributable to  the  continuance  of  the  cause  that  gave  rise  to 
them  in  the  first  instance,  or  to  their  imperfect  removal. 
That  they  do,  however_,  sometimes  originate  in  the  ethmoi- 
dal cells,  there  can  be  no  question. 

It  sometimes  happens  that  tumors  having  their  seat  in  the 
antrum,  after  having  filled  it,  make  their  way  into  the  nose 
where  they  acquire  a  size  equal  to,  or  even  greater  than 
that  wliich  they  had  previously  attained,  thus  dividing 
themselves,  as  it  were  into  two  parts — one  occupying  the 
antrum,  and  the  other  one  of  the  nasal  cavities.  Occur- 
rences of  this  sort  are  not  unfrequent,  and  they  sometimes 
lead  to  the  adoption  of  an  incorrect  opinion  with  regard  to 
the  real  seat  of  the  disease.  Thus,  a  polypus  of  the  antrum 
is  occasionally  mistaken  for  one  of  the  nose,  and  the  error 
frequently  not  discovered,  until  an  attempt  is  made  to  re- 
move it. 

The  character  of  morbid  growths,  in  this  cavity,,  is  exceed- 
ingly variable,  as  much  so  as  is  the  state  of  the  constitution- 
al healtli  of  different  individuals,  and  the  causes  that  give 
rise  to  them.  They  not  only  vary  in  their  appearance  and 
structure,  but  they  vary  in  their  malignancy.  Some  are  of  a 
healthy  flesh  color,  soft,  sensitive,  but  not  painful,  and  pre- 
sent a  smooth,  regular  surface  ;  others  varying  in  their  con- 
sistence from  hard  to  soft,  and  in  their  color  from  pale  yel- 
low to  deep  red  or  purple,  present  a  rough,  irregular,  and 
not  unfrequently  ulcerated  surface,  and  are  more  or  less  sen- 
sitive to  the  touch.  Some  have  their  origin  in  the  mucous 
membrane^  and  others,  both  in  this  and  the  periosteum. 
Some  are  attached  by  a  broad  base,  and  others,  only  by  a 
mere  peduncle. 

As  it  regards  this  latter  description  of  tumors,  which  are 
usually  designated  by  the  name  of  polypi,  their  occurrence  in 
the  maxillary  sinus  is  questioned  by  some  writers.  Sir  Ben- 
jamin Brodie  does  not  believe  they  ever  form  in  this  cavity ;  * 

*  Vide  London  Medical  Gazette,  for  December,  1834,  p.  850. 


620  TUMORS   OF  LINING   MEMBRANE   AND    PERIOSTEUM. 

and  in  this  opinion  Mr.  S.  Cooper  fully  concurs  ;  but  that 
they  are  occasionally  met  with,  seems,  nevertheless^  to  he 
conclusively  established.  A  case  described  by  M.  Bertran- 
di  in  his  treatise  on  Operative  Surgery,  page  369,  has  al- 
ready been  referred  to  ;  and  Bordenave,  in  his  observations 
on  the  diseases  of  the  antrum  maxillare,  gives  the  history  of 
a  case  treated  by  M.  Doublet.  Rusch  declares  that  he  has 
twice  seen  polypus  of  this  cavity,  and  Petitt,  Levrette  and 
other  writers  also  affirm  that  they  have  witnessed  polypi 
here.*  The  occurrence,  then,  of  polypi  in  the  maxillary 
sinus^  although  very  rare,  it  must  be  admitted,  docs  some- 
times happen.  Other  descriptions  of  tumors  are  certainly 
more  frequently  met  with  in  this  cavity.  Of  these,  some 
are  of  a  simple  fibrous,  sarcomatous,  or  osteo-sarcomatous 
nature, t  and  when  thoroughly  extirpated,  are  seldom  re- 
produced ;  others  are  of  a  medullary,  cancerous,  or  carcino- 
matous character.  These  last,  although  originating  in  the 
mucous  membrane,  if  long  neglected,  are  very  liable  to  be 
reproduced  after  their  removal,  and  generally  occasion  the 
death  of  the  patient. 

It  sometimes  happens  that  several  fungi,  and  from  oppo- 
site and  various  points  spring  up.  The  chances  of  cure, 
when  this  is  the  case,  especially  if  they  are  of  a  malignant 
character,  are  greatly  lessened. 

Tumors  of  this  cavity  seldom  grow  very  fast  during  the 
early  stages  of  their  formation  ;  but,  as  they  enlarge,  the 
neighboring  parts  become  involved  in  the  diseased  action, 
and  consequently  furnish  them  with  fluids  less  healthy  in 
their  qualities,  and  thus  cause  them  to  assume  a  character 
of  greater  malignancy,  and  generally  to  increase  more  rap- 
idly in  size. 

*  Vide  Traite  des  Maladies  de  la  Bouch,  torn.  1,  p.  212,  and  sur  cure  des  Polypes 
de  la  niatrice,  de  la  gorge,  et  du  nez,  p.  253. 

+  Vide  ProfesBor  Reese's  Appendix  to  Cooper's  Surgical  Dictionarj,  American 
edition,  1842. 


SYMPTOMS   OP  TUMORS,    &C.  621 


SYMPTOMS. 


The  occurrence  of  tumors  in  the  maxillary  sinus  is  rarely 
accompanied,  previously  to  having  obtained  a  size  sufficient- 
ly large  to  fill  it,  by  symptoms  differing  materially  from 
those  occasioned  by  many  of  the  other  affections  that  locate 
themselves  here.  After  they  have  filled  the  sinus,  the  in- 
dications soon  become  less  eq[uivocal.  Swelling  of  the 
cheek,  depression  of  the  palatine  arch  and  alveolar  ridge, 
loosening  of  the  superior  molar  teeth  of  the  affected  side, 
inflammation  and  sponginess  of  the  gums,  elevation  of  the 
floor  of  the  orbit,  and  protrusion  or  concealment  of  the  eye, 
are  symptoms  which  result  from  the  presence  of  tumors  in 
this  cavity,  but  they  are  not  peculiar  to  these  affections 
alone  ;  many  of  them  are  produced  by  mucous  engorgement 
of  the  sinus.  When  to  these  is  superadded  the  discharge 
of  bloody  sanies  from  the  nose,  or  from  one  or  more  fistulous 
openings  through  the  cheek,  alveolar  ridge,  or  palatine, 
arch,  the  diagnosis  will  be  conclusive  ;  and  the  existence  of 
a  tumor  in  the  antrum  be  established  beyond  doubt. 

There  are  also  other  signs  by  which  the  occurrence  of  a 
morbid  growth  in  this  cavity  may  be  known  ;  as  for  exam- 
ple :  dropping  out  of  the  superior  molars  of  the  affected  side, 
and  the  protrusion  of  portions  of  the  tumor  through  the 
alveoli. 

The  pain  is  seldom  severe  until  the  tumor  has  filled  the 
cavity,  except  the  excrescence  is,  from  its  inception,  of  a 
malignant  character;  as  it  augments  in  size  and  forces  the 
walls  of  the  sinus  asunder,  it  becomes  more  and  more 
severe.  Sometimes,  during  the  progress  of  the  disease,  it 
becomes  almost  excruciating.  In  a  case  of  fungous  hema- 
todes  of  this  cavity,  which  the  author  had  an  opportunity 
of  witnessing  in  1835,  the  patient  was  in  the  habit  of  taking 
upwards  of  two  tea-spoonfuls  of  black  drop  at  a  time,  for  the 
procurement  of  ease  and  sleep. 

In  addition  to  the  foregoing  symptoms,  several  of  the  af- 


622  TREATMENT   OF   TUMORS,    &C. 

fections  already  treated  on,  together  with  all  the  effects  pro- 
duced by  them,  not  unfrequently  result  from  tumors  in  this 
cavity.  Inflammation  and  ulceration  of  its  lining  mem- 
brane, a  purulent  condition  of  its  secretions,  caries,  necrosis, 
and  softening  of  its  osseous  walls,  seldom  fail  to  attend 
some  of  the  stages  of  the  formation  of  the  morbid  produc- 
tions under  consideration.  It  is  unnecessary  to  mention  the 
symptoms  peculiar  to  each  variety  of  tumor,  as  they  are 
given  by  writers  on  general  surgery. 

CAUSES, 

Most  writers  on  the  affections  of  the  maxillary  sinus,  are 
of  opinion  that  tumors  in  this  cavity  result  spontaneously, 
as  a  consequence  of  some  specific  constitutional  vice,  inde- 
pendently of  local  causes.  We  do  not  believe  that  they  are 
ever  developed  spontaneously.  That  a  bad  habit  of  body, 
or  some  constitutional  vice  is  necessary  to  the  production  of 
the  affections  under  consideration,  is  very  probable,  but  that 
this  is  capable  of  giving  rise  to  them  in  parts  uninfluenced 
by  local  irritation,  we  think  exceedingly  questionable. 
Having,  however,  already  expressed  our  views  with  regard 
to  the  agency  of  particular  habits  of  body  and  constitutional 
vices  in  the  production  of  disease  in  this  cavity,  it  will  not 
be  necessary  to  repeat  what  we  have  before  said  upon  the 
subject.  It  will  be  sufficient  to  remark  that  most,  if  not  all 
of  the  morbid  excrescences  met  with,  result  from  local  irri- 
tation, favored  by  constitutional  vices;  and  that  both  are 
necessary  to  their  production. 

TREATMENT. 

It  is  only  in  the  earlier  stages  of  the  formation  of  tumors 
in  this  cavity,  that  surgical  treatment  can  be  adopted  with 
success,  and  even  then,  their  entire  extirpation  is  necessary. 
Without  this,  a  speedy  return  of  the  disease  may  be  expect- 


TREATMENT   OF    TUMORS,    <feC.  623 

ed.  But,  preparatory  to  the  removal  of  the  diseased  struc- 
ture, a  large  opening  should  be  made  into  the  antrum,  so 
as  to  expose  as  much  of  it  as  possible ;  and  with  regard  to 
the  most  proper  place  for  effecting  this,  Deschamps  recom- 
mends, when  the  alveolar  ridge  has  been  started,  the  re- 
moval of  the  first  or  second  molar,  and  the  perforation  of 
the  sinus  tlirough  its  socket  with  a  ^-'three-sided  trocar  of 
suitable  dimensions."  When  the  alveolar  ridge  and  teeth 
are  sound,  he  directs  the  opening  to  be  made  through  the 
outer  wall  of  the  sinus  above  the  ridge,  and  th'^^,  he  thinks, 
on  account  of  its  being  more  direct,  is  preferable  to  the  other 
mode.  An  opening  may  be  easily  effected  in  either  way 
into  the  sinus,  as  its  walls  are  generally  so  much  softened 
as  to  offer  but  little  resistance. 

When  the  opening  is  made  through  the  external  parietes, 
the  instrument  recommended  by  Mr.  Thomas  Bell,  for  cut- 
ting away  the  bone  after  it  has  been  exposed,  is  a  "strong 
hooked  knife,"  which  is  probably  as  well  adapted  to  the 
purpose  as  any  that  can  be  used.  Some  surgeons  employ 
strong  curved  scissors,  but  the  hook  knife  we  think  pre- 
ferable. 

A  free  opening  having  been  effected,  a  finger  of  the  ope- 
rator should  be  introduced,  and  the  nature  of  the  diseased 
structure  ascertained.  This  done,  he  will  be  able  to  deter- 
mine the  proper  procedure  to  be  had  recourse  to  for  its  re- 
moval .  If  the  tumor  partakes  of  the  character  of  polypi,  it 
maybe  seized  with  a  pair  of  forceps,  and  torn  away;  if  it  be 
attached  b}'^  a  broad  base,  its  extirpation  will  be  most  readily 
effected  with  a  knife.  But  even  with  this,  it  is  often  ex- 
ceedingl}^  difficult  to  effect  its  total  removal,  so  that  it  not 
unfrequently  becomes  necessary  to  employ  the  actual  cau- 
tery;  for,  if  any  small  portions  be  left  beliind,  as  has  before 
been  stated,  a  reproduction  of  the  disease  v.  ill  generally 
very  soon  take  place.  When  the  disease  has  (  riginated,  oi 
is  seated  in  the  periosteum,  the  cautery  has  proved  to  be  the 
most  effectual  means  of  preventing  its  return.  French 
surgeons  have  applied  it  with  great  success.     Desault,  in  a 


624  TREATMENT   OF   TUMORS,    <feC. 

case  of  fungous  tumor,  succeeded  in  effecting  a  cure,  after 
three  applications.  The  root  of  the  disease^  by  the  employ- 
ment of  this,  can  often  be  destroyed,  when  less  eifectual 
means  would  fail.  But  it  is  important,  when  it  is  had  re- 
course to,  that  it  should  have  such  a  degree  of  heat,  as  to 
accomplish  the  object  instantaneously,  else  the  inflammation 
that  would  otherwise  be  excited  by  its  application  in  the 
surrounding  parts,  would  greatly  retard,  if  it  did  not  pre- 
vent^ the  cure.  The  remarks  of  Mr,  Thomas  Bell  upon  this 
subject,  who  says,  "the  white  heat  should  be  employed," 
are  worthy  of  attention. 

In  remarking  upon  the  bold  practice  of  the  French  sur- 
geons in  the  treatment  of  these  affections,  the  author  just 
quoted  says,  "it  is  worthy  of  our  praise  and  imitation;" 
and,  continues  he,  "the  timidity  which,  until  very  lately^ 
almost  excluded  the  use  of  the  actual  cautery  in  this  coun- 
try, has  been  one  cause,  and  that  a  very  prevalent  one,  of 
failure  in  the  treatment  of  some  of  these  cases  ;  but  it  is  not 
so  easy  to  account  for  the  still  more  culpable  dread,  which 
has,  in  so  many  instances,  prevented  any  attempt  from  be- 
ing made  to  extirpate  the  disease  ;  a  degree  of  pusillanimity, 
which  is  at  once  an  opprobrium  on  the  profession  and  a  fatal 
injustice  to  the  sufferers,  who,  thus  abandoned  to  the  unre- 
strained progress  of  the  disease,  are  left  to  perish  b}''  a 
lingering  and  most  painful  process,  without  even  an  attempt 
being  hazarded  for  their  relief." 

The  foregoing  comparison,  instituted  by  Mr.  Bell,  be- 
tween the  practice  of  the  French  and  English  surgeons  in 
the  treatment  of  tumors  of  the  maxillary  sinus,  is  certainly 
correct.  But  it  is  due  to  truth  to  say,  that  the  bold  prac- 
tice of  the  former  has  been  fully  and  successfully  emulated 
by  American  surgeons.  Dr.  A.  H.  Stevens,  Professor  of 
Surgery  in  the  University  of  New  York,  in  1823,  in  a  case  of 
fungous  tumor,  attached  by  a  broad  base  to  the  lower  part 
of  the  antrum,  removed  a  large  portion  of  the  lower  and 
anterior  parts  of  the  upper  jaw.     The  patient  recovered. 


TREATMENT   OF    TUMORS,    <feC.  625 

and  is  said  to  be  living  at  the  present  time,  1844.*  In  1841, 
Dr.  J.  C.  Warren,  of  Boston,  for  a  case  of  ceplialomatous 
tnmor  of  this  cavity,  removed  the  superior  maxillary  bone. 
This  operation  was  also  successful. f  The  same  operation 
was  performed  soon  after,  and  for  the  removal  of  a  tumor  of 
the  antrum  with  success,  by  Dr.  K.  D.  Mussey,  of  Cincin- 
nati, Ohio, I  and  Dr.  Fare,  of  Columbia,  South  Carolina, 
has  performed  the  operation  twice  with  success. 

Thus  it  is  perceived,  that  the  disease  under  consideration 
not  unfrequently  calls  for  one  of  the  most  formidable  opera- 
tions in  surgery,  and  that  by  it,  many  unfortunate  sufferers 
have  been  snatched  from  the  very  jaws  of  death.  The  ap- 
plication of  the  cautery,  notwithstanding,  often  becomes 
necessary  to  prevent  a  reproduction  of  the  excrescence,  and 
there  are  many  cases  in  which  it  cannot  be  repressed  even 
by  this  means.  The  result  of  the  most  thorough  and  best 
directed  treatment  depends  on  the  state  of  the  constitutional 
health  and  the  nature  of  the  disease.  In  depraved  habits 
and  shattered  constitutions,  if  the  tumor  is  of  a  carcinoma- 
tous character,  a  cure  need  never  be  expected. 

The  hemorrhage,  during  the  operation  for  th:  removal  of 
tumors  of  the  antrum,  is  sometimes  so  profuse  as  to  require 
very  prompt  and  active  means  to  arrest  it.  It,  may,  gene- 
rally, however,  be  controlled  by  the  employment  of  com- 
presses and  suitable  styptics;  should  these  fail,  the  actual 
cautery  must  be  resorted  to. 

The  history  of  the  following  cases  taken  promiscuously 
from  various  works,  will  perhaps  furnish  a  more  correct  idea 
of  the  methods  of  treatment  most  proper  to  be  pursued  than 
any  description  which  could  otherwise  be  given.  The  first 
three  cases  are  taken  from  the  Memoirs  de  1' Academic 
Roy  ale  de  Chirurgie.§ 

Case  15th.  A  man  about  thirty-five  years  of  age,  had  a 

*  Appendix  to  Cooper's  Surg;ical  DictioD.ay,  p.  30. 
t  Boston  Jledical  and  Suro;ical  Journal  Cor  1842. 
4:  Western  Lancet  for  1842. 
§  Tome  13,  obs.  1,  5  and  7th,  pp.  372,  387  and  424. 


626  TREATMENT   OF   TUMORS^    &C. 

flesliy  tumor,  the  size  of  a  large  pea^  situated  in  a  space 
formed  by  the  decay  of  the  first  and  second  superior  molars 
of  the  left  side.  This  tumor  caused  a  dull  pain  ;  it  was  ex- 
cised, and  the  actual  cautery  applied  to  arrest  the  bleeding 
and  destroy  the  remaining  portions  of  the  excrescence.  It 
re-appeared,  and  three  months  after  was  double  the  size  of 
the  former,  and  impeded  mastication.  The  two  decayed 
teeth  were  loose,  and  the  others  were  painful ;  and  fetid 
matter  escaped  through  the  nose  and  mouth. 

After  the  extraction  of  the  two  decayed  teeth,  M.  Duber- 
trand,  discovering  that  the  tumor  had  its  seat  in  the  antrum, 
seized  it  with  polypi  forceps  and  brought  the  whole  of  it 
away.  After  the  extraction  of  the  tumor,  the  opening 
through  the  alveolus  was  large  enough  to  admit  the  little 
finger.  M.  Dubertrand  next  destroyed  such  portions  of  the 
alveoli  and  maxillary  bone  as  were  decayed.  After  the  ex- 
tirpation of  the  tumor,  he  found  it  necessary  to  introduce  a 
plug  of  cotton  into  the  antrum,  to  arrest  the  hemorrhage 
that  followed  the  operation. 

The  secretions  of  the  maxillary  sinus  ceased  to  exhale  an 
unpleasant  odor  ;  in  three  days  they  became  healthy,  and 
in  less  than  one  month,  the  patient  was  restored  to  health, 
and  the  opening  from  the  mouth  into  this  cavity  was  closed 
with  firm  granulations. 

The  tumor  just  described  was  of  the  simplest  kind,  but 
had  it  not  been  completely  eradicated,  it  would,  doubtless, 
have  soon  re-appeared. 

Case  16th.  Acoluthus  reports  the  case  of  a  woman  thirty 
years  of  age,  who,  in  1693,  came  to  Pologne  in  Silesia,  in 
search  of  aid  for  a  peculiar  disease  of  the  antrum,  under 
which  she  was  laboring.  Some  time  after  the  extraction  of 
a  tooth  from  the  left  side  of  the  upper  jaw,  a  small  tumor 
appeared  in  its  alveolus,  and  made  such  progress  that  in  two 
years  it  attained  the  size  of  a  double  fist.  It  occupied 
nearly  the  whole  cavity  of  the  mouth,  and  distended  the 
jaw  to  such  a  degree  that  it  was  feared  it  would  rupture  it. 


4 


TREATMENT   OF   TUMORS,    &C.  627 

The  lower  jaw  was  depressed,  the  lips  could  not  be  made  to 
meet,  and  the  tumor  increased  so  fast,  that  in  a  few  weeks 
the  woman's  life  was  despaired  of — she  being  threatened 
with  death  from  suffocation,  hunger  and  thirst.  Under 
these  circumstances,  Acoluthus  determined  to  attempt  a 
cure. 

The  tumor  was  very  hard,  and  occupied  tlie  greatest  part 
of  the  palatine  arch  ;  the  upper  teeth  of  the  left  side  were 
in  its  centre.  The  operation  was  commenced  by  enlarging 
the  mouth,  beginning  at  the  commissure  of  the  lips,  and 
passing  it  transversely  through  the  cheek.  This  enabled 
Acoluthus  to  attack  tlie  exterior  of  the  tumor  with  a  curved 
bistoury.  The  excrescence  was  as  hard  as  cartilage,  and 
scarcely  yielded  to  cutting  instruments  applied  by  a  strong 
hand.  He,  however,  succeeded  in  bringing  three  or  four 
teeth,  together  with  a  portion  of  the  superior  maxillary 
bone.  The  operation  as  yet  had  extended  only  to  the  ex- 
terior half  of  the  tumor  ;  the  other  which  filled  the  pala- 
tine fossa_,  he  says,  it  was  impossible  to  bring  away.  The 
removal  of  that  was  effected  only  by  piecemeal^  and  at 
different  times.  The  operation  was  long,  laborious  and  very 
painful.  The  actual  cautery  was  applied  to  the  bleeding 
vessels  and  fungous  flesh.  The  appearance  of  the  patient,  a 
few  days  after  the  operation,  was  such  as  to  inspire  hope  for 
a  favorable  termination  of  the  disease.  The  actual  cautery 
was  applied  several  times,  and  finally  there  was  no  indica- 
tions of  a  re-appearance  of  the  excrescence,  except  at  the 
point  where  it  liad  first  originated.  Some  portions  of  bone 
were  afterwards  found  to  be  carious,  and  the  removal  of 
these  was  followed  by  a  prompt  aud  speedy  cure. 

This  operation  is  alluded  to  by  M.  Velpeau,  as  embracing 
the  removal  of  the  entire  superior  maxillary  bone,  but  from 
the  description  here  given,  it  would  appear  that  only  a  small 
portion  of  the  bone  was  taken  away.  The  alveolor  ridge 
and  anterior  parietes  of  the  sinus  is  all  that  was  removed. 
Tlie  history  of  the  case,  however,  imperfect  as  it  is,  and  the 
result   of  the  treatment,  proves    that  the  resources  of  art 


628  TREATMENT   OF   TUMORS,    &C. 

are  adequate  to  tlie  cure  of  many  of  the  most  formidable  of 
tlie  affections  of  this  cavity^  if  they  are  not  delayed  too 
long. 

Another  case,  taken  from  the  memoirs  of  the  Royal 
Academy  of  Surgery,  is  described  by  the  author  in  his  dis- 
sertation on  the  diseases  of  this  cavity  ;  for  the  particulars 
of  which,  the  reader  is  referred  to  page  131,  of  that  work. 

Case  17th.  A  young  lady  of  Picardy  having  been  exposed 
to  the  changes  of  weather  for  three  years,  in  attending  to 
business  which  required  of  her  to  be  much  on  horseback, 
experienced^  at  the  end  of  the  first  year^  a  chilly  sensation 
in  her  left  cheek  ;  this  increased,  and  her  cheek  became 
swollen,  and  her  molar  teeth  of  the  affected  side  loosened, 
and  two  dropped  out. 

The  swelling  of  her  cheek  increased_,  and  she  was  affected 
with  lancinating  pains  in  that  side  of  her  face  ;  her  breath 
became  offensive,  and  she  lost  two  more  teeth.  Becoming 
alarmed,  she  went  to  Rouen  to  obtain  medical  advice.  Re- 
ceiving no  satisfaction,  she  went  to  Paris_,  and  applied,  No- 
vember 20th,  1740,  to  M.  Croissant  de  Grarengeot,  who  found 
her  face  greatly  disfigured.  Her  mouth,  he  says,  was  on 
the  right  side,  the  left  side  of  her  nose  much  elevated,  the 
left  cheek  very  large,  and  the  upper  lip  of  the  same  size 
greatly  thickened.  Bluish  flesh  of  the  size  of  an  olive  occu- 
pied the  alveoli  of  the  teeth  which  had  dropped  out,  the  left 
side  of  the  roof  of  the  palate  was  thrown  inwards  and  re- 
sembled the  exterior  projection  of  the  cheek.  The  anterior 
wall  of  the  antrum  and  left  nasal  bone,  had  become  softened, 
and  the  whole  cavity  was  filled  with  fungous  flesh. 

M.  Garengeot  commenced  the  operation  by  seizing  the 
bluish  excrescence,  which  had  appeared  through  the  alveoli, 
with  a  hook  and  cutting  it  awav  ;  and  he  says  he  incised 
transversely,  every  day,  from  within  the  mouth,  the  bucci- 
nator muscle,  and  brought  away  part  of  it  as  well  as  the 
flesh  which  so  much  augmented  the  size  of  the  jaw. 

The  hemorrhage  was  so  abundant  that  it  was  impossible 


TKEATMENT   OF   TUMOES,    &C.  629 

to  proceed  furtber  with  the  operation.  The  excrescence  was 
rapidly  reproduced  after  each  operation  ;  these  excisions 
were  repeated  seven  or  eight  times  in  six  weeks,  a'?id  the 
hemorrhage,  each  time  was  very  great.  The  seat  of  the 
disease  was  in  the  anterior  of  the  sinus.  The  fungous  flesh 
contained  in  this  cavity  was  removed,  as  well  also  as  some 
osseous  projections. 

The  excrescence  continuing  to  he  reproduced,  the  patient 
no  longer  refused  to  have  the  actual  cautery  applied  ;  the  use 
of  which  was  resorted  to,  twice  a  day,  for  eight  days.  The 
success,  says  M.  Garengeot,  which  followed  this  treatment, 
was  incredible.  The  flesh  soon  took  on  a  health}'  consist- 
ence, the  palatine  arch  returned  about  two-thirds  to  its 
natural  situation_,  and  the  bad  odor  of  the  mouth  gradually 
disappeared. 

The  application  of  the  cautery  was  continued,  once  a  day, 
for  three  weeks,  and  the  patient  did  nothing  more  than  to 
use  a  slightly  stimulating  and  astringent  gargle.  On  the 
20th  of  March  she  returned  home  cured. 

It  is  very  probable  that  had  the  operation  in  the  case  just 
described  been  thorough,  there  would  have  been  no  return 
of  the  disease,  for  it  is  evident  from  the  description  which 
M.  Garengeot  gives  of  the  operation,  that  the  seat  of  the 
affection  was  not  reached  until  it  had  been  repeated  seven  or 
eight  times  ;  and  then,  we  think  it  very  likely,  not  until  he 
had  recDurse  to  the  actual  cautery. 

The  utility  of  the  actual  cautery,  not  only  for  the  i)urpose 
of  thoroughly  destroying  every  remaining  vestige  of  fungous 
tumors  of  the  antrum  maxillare  after  their  removal,  but  also 
for  the  suppression  of  hemorrhage,  would  seem  to  be  fully 
established  by  the  result  of  the  treatment  of  cases  sixteen 
and  seventeen. 

The  employment  of  arsenical  preparations  has,  in  some 
instances,  been  found  highly  advantageous  in  repressing  the 
growth  of  fungous  excrescences.  The  following  case  is  cited 
by  Mr.  Thomas  Bell  as  an  example.* 

*  Anat  Phjs.  and  Diseases  of  the  Teeth,  p.  283. 


630  TREATMENT   OF   TUMORS^    AC. 

Case  18th.  "James  Wooclley  was  admitted  into  Guy's 
Hospital,  September  4th,  1821,  for  a  fungous  exostosis, 
which 'arose  from  the  antrum  maxillare,  and  made  its  way 
through  the  palate.  After  his  admission  he  had  the  fun- 
gous removed  two  or  three  times,  and  a  variety  of  caustic 
applications  were  afterwards  made  use  of;  notwithstanding 
which  the  tumor  re-appeared.  At  length  Sir  A.  Cooper, 
after  having  made  an  incision  from  the  corner  of  the  mouth 
outwards  through  the  cheek,  removed  the  tumor  from  a 
greater  depth  than  had  previously  been  effected.  After  this 
operation,  the  wound  in  the  cheek  readily  healed,  and  the 
following  strong  solution  of  arsenic  was  daily  applied  to  the 
part  from  whence  the  tumor  had  been  removed. 

R     Arsenic,  oxyd.  alb.  3  vi. 
Potass,  subcarb.  q.  s. 
Aq.  distillat.  M.  ft.  solutio. 

"The  solution  required  to  be  diluted  in  the  first  instance 
on  account  of  its  occasioning  him  a  good  deal  of  pain  ;  in  a 
few  days,  however,  he  used  it  of  the  strength  mentioned  in 
the  formula.  It  was  applied  regularly  every  afternoon, 
after  which  he  did  not  take  any  food  until  the  following 
day.  At  the  time  of  its  application  he  had  a  piece  of  oiled 
silk,  of  a  horse-shoe  shape,  passed  into  the  mo|^h,  its  sides 
being  turned  up  to  prevent  the  solution  escaping  into  the 
mouth  ;  his  head  then  hanging  down  over  a  basin,  a  piece 
of  sponge  moderately  saturated  with  the  solution  was  ap- 
plied to  the  disease  upon  the  oiled  silk,  pressed  against  the 
part ;  such  of  the  solution  as  was  then  pressed  out,  passed 
along  the  channel  of  the  oiled  silk  into  the  basin  over  which 
the  head  was  hanging,  and  the  saliva  escaped  behind  the 
oiled  silk  into  the  same  utensil.  He  kept  the  sponge  in 
this  situation  until  it  gave  him  considerable  pain,  when  it 
was  removed  and  the  mouth  carefully  washed.  He  suffered 
great  pain  in  his  mouth  during  the  period  of  cure  ;  but  the 
arsenic  did  not  produce  any  other  unpleasant  symptoms. 


TREATMENT   OF  TUMORS,  &G.  631 

This  application  was  continued  for  a  few  weeks,  at  the  end 
of  which  time  he  was  completely  cured  ;  a  cavity  being  left 
in  the  site  of  the  tumor,  which,  however,  gradually  became 
covered  by  a  continuation  of  the  membrane  which  naturally 
lines  the  j)alate." 

The  maxillary  sinus  is  sometimes  occupied  by  fungous 
tumors,  originating  in  the  alveoli  of  the  molar  teeth,  or 
from  the  roots  of  these  teeth.  The  following  is  a  case 
which  came  under  the  observation  of  the  author  in  Febru- 
ary, 1846  : 

Case  19th.  Miss  L ,  of  Baltimore,  a3t.  twenty-two,  of 

a  bilious  temperament,  called  to  consult  us  in  relation  to 
the  condition  of  her  teeth,  on  the  10th  of  February,  1846. 
On  examination,  the  crowns  of  the  first  and  second  superior 
molars  of  the  left  side  were  found  badly  decayed,  and 
which,  from  the  destruction  of  the  greater  portion  of  their 
sockets,  were  much  loosened.  The  gums  on  either  side 
were  much  swollen,  spongy  and  had  a  livid  appearance  ; 
from  between  the  edges  of  which,  whenever  the  teeth  were 
touclied_,  thin,  fetid  matter,  occasionally  streaked  with  blood 
and  pus,  was  discharged.  She  complained  of  a  sensation 
of  fulness,  and  occasionally  of  slight  pain  in  lier  left^ 
cheek.  The  affected  molars  liad  been  troublesome  and  sen- 
sitive to  the  touch  for  nearly  three  years,  arising,  as  she 
supposed,  from  a  severe  cold,  as  she  suffered  about  that 
time,  for  near  two  weeks^  the  most  violent  pain  in  tliese 
teeth.  Slie  had  several  times,  subsequently,  been  urged  by 
her  friends  to  have  the  teeth  removed,  but  the  fear  of  pain 
had  prevented  her  from  submitting  to  the  operation. 

Fearing  that  the  diseased  condition  of  the  sockets  of  the 
affected  molars  had  extended  to  the  antrum  maxillare,  and 
confident  that  the  parts  immediately  involved  could  not  be 
restored  to  health  while  they  remained  in  tlio  mouth,  we 
advised  her  to  have  them  removed.  After  much  persuasion, 
she  consented  to  the  operation. 

The  gums  being  separated  from  the  teeth,  we  at  once 


632  TREATJIENT   OF   TUMORS,  &C. 

grasped  the  first  molar  with  a  pair  of  forceps,  and  proceeded 
to  remove  it.  It  readily  yielded  to  a  very  slight  force,  but 
the  moment  this  was  applied,  a  gush  of  hlood  issued  from 
the  left  nostril,  and  the  complete  removal  of  the  tooth  being 
prevented  by  a  fungous  excrescence  which  had  originated  at 
the  extremity  of  its  roots,  and  passed  up  into  the  antrum, 
the  true  nature  of  the  affection  at  once  suggested  itself  to 
our  mind.  The  tooth,  after  being  partially  removed,  was 
liberated  by  cutting  the  excrescence. 

The  hemorrhage  for  a  few  minutes  was  profuse,  but  after 
it  had  partially  subsided,  the  socket  was  examined,  when 
an  opening  was  discovered  through  the  floor  of  the  antrum, 
large  enough  to  admit  the  end  of  the  little  finger — the  fun- 
gous peduncle,  after  its  separation  from  the  roots  of  the 
tooth,  having  contracted,  had  passed  up  into  this  cavity. 
This  was  now  partially  explored  by  means  of  a  small  probe, 
and  found  to  be  nearly  filled  with  a  soft  spongy  tumor, 
which  bled  profusely  from  the  slightest  injury.  Finding  a 
portion  of  the  floor  of  the  antrum,  back  of  tlie  tooth  which 
had  just  been  extracted,  in  a  necrosed  condition,  and  par- 
tially exfoliated,  we  extracted  the  second  molar,  which  also 
had  a  fungous  excrescence  upon  the  extremity  of  its  roots, 
which  passed  up  through  an  opening  from  the  socket  into 
this  cavity,  and  then  removed  the  dead  bone.  This  occu- 
pied the  space  between  the  two  teeth. 

An  opening  was  now  formed  through  the  floor  of  the  an- 
trum, of  about  an  inch  in  length,  and  more  than  a  quarter 
of  an  inch  in  width,  which  enabled  us  to  explore  the  inte- 
rior of  the  cavity  more  thoroughly  than  we  had  previously 
been  able  to  do.  The  tumor,  which  at  first  had  completely 
filled  it,  had,  from  the  hemorrhage  occasioned  by  the  lace- 
ration of  the  vessels,  become  so  reduced  in  size,  that  we 
were  enabled  to  pass  a  small  curved  probe  between  it  and 
the  walls  of  the  sinus,  and  by  this  means,  to  satisfy  ourself 
that  it  had  no  connection  with  any  part  of  the  cavity. 
There  was  no  danger,  therefore,  to  be  apprehended  of  a  re- 
production of  the  excrescence  after  its  removal,  which  was 


TREATMENT   OF  TUMORS,  &C.  633 

easily  affected,  by  piecemeal,,  with,  a    small  sliarp-pointed 
hook,  and  a  narrow  bladed  knife. 

The  opening  through  the  alveolar  border,  into  the  an- 
trum, soon  closed,  and  the  parts,  in  a  short  time,  were 
restored  to  a  healthy  condition. 

What  would  have  been  the  result,  in  this  case,  had  the 
teeth  been  permitted  to  remain,  is  not  difficult  to  conjecture. 
The  pressure  of  the  excrescence,  as  it  augmented  in  size, 
would  have  caused  necrosis  of  the  entire  floor,  if  not  of  the 
walls  of  the  antrum,  which  would  ultimately  have  become 
detached  and  displaced,  carrying  it  and  the  diseased  teeth 
with  them.  But,  in  the  meantime,  other  parts  might  have 
become  involved  in  a  worse  and  more  unmanageable  form 
of  disease. 

In  the  treatment  of  tumors  of  this  cavity,  it  sometimes 
becomes  necessary  for  their  complete  eradication  to  remove 
the  entire  superior  maxillary  bone,  and  the  following  is  the 
method  jDursued  by  Mr.  Liston  in  the  performance  of  this 
formidable  operation :  The  extent  of  the  disease  being 
accurately  ascertained,  the  points  of  separation  are  decided 
upon.  Supposing  the  malar  bone  involved,  the  instru- 
ments employed,  are  a  pair  of  straight  tooth  forceps,  a  full 
sized  histoury,  copper  spatula,  powerful  scissors,  artery  for- 
ceps, a  small  saiv,  and  needles  for  interrupted  and  tivisted 
suture. 

Thus  armed,  he  commences  the  operation  by  extracting  a 
central  incisor,  either  on  the  affected  side  or  the  opposite, 
as  the  size  of  the  tumor  may  require.  The  point  of  the  bis- 
toury is  then  carried  from  the  external  angular  process  of 
the  frontal  bone  down  to  the  corner  of  the  mouth  through 
the  cheek  ;  the  incision  being  guided  by  placing  the  fore 
and  middle  fingers  in  the  cavity  of  the  mouth.  A  second 
incision  is  made  along  the  zygoma,  and  connects  with  the 
first.  The  knife  is  now  pushed  through  the  integument  to 
the  nasal  process  of  the  superior  maxilla,  detaching  the  ala 
from  the  bone,  and  cutting  the  lip  through  in  the  middle 
line. 

41 


634  TREATMENT   OF   TUMORS^  &C. 

The  flap  is  dissected  up  and  held  by  an  assistant ;  the 
soft  partSj  as  the  inferior  obli(|ue  muscle,  infra-orbitar  nerve, 
and  attached  to  the  floor  of  the  orbit  are  cut,  and  its  con- 
tents supported  by  a  narrow  bent  spatula. 

The  section  of  the  bone  comes  next  in  order.  This  is 
made  with  the  cutting  forceps,  dividing  in  succession,  the 
junction  of  the  malar  bone,,  the  zygomatic  arch,  the  nasal 
process  of  the  superior  maxilla,  and  then  with  strong  scis- 
sors, after  having  notched  the  alveolar  process,  one  blade  is 
passed  in  the  mouth,  and  the  other  in  the  nostril  of  the 
affected  side,  the  palatine  arch  is  cut  through.  At  this 
stage,  the  carotid  artery,  if  necessary,  is  compressed.  The 
tumor  is  now  turned  down  from  its  bed,  and  the  remaining 
attachments  divided,  preserving,  if  possible^  the  palatine 
plate  of  the  palate  bone  with  the  velum  palati.  The 
branches  of  the  internal  maxillary  being  torn  and  stretched 
may  not  require  a  ligature.  The  patient  being  now  placed 
in  a  reclining  ])osture,  the  cavity  sponged  out  and  exam- 
ined, and  all  vessels,  whether  bleeding  or  not,  that  are 
seen,  secured  with  a  ligature,  and  tlie  ends  cut  off.  The 
space  occupied  by  the  tumor  and  removed  structures  are 
filled  with  lint,  and  the  edges  of  the  wound  united  with 
either  tlie  interrupted  or  twisted  suture.  No  dressing  is 
applied — plasters^  bandages,  etc.,  being  thought  useless.  In 
twenty-four  hours,  some  of  tlie  sutures  are  withdrawn,  and 
plasters  then  applied  ;  in  forty-eight  hours  they  are  all  re- 
moved, the  wound  at  this  time  having  adhered. 

Other  methods  have  been  proposed  for  excision  of  tlie 
upper  jaw.  Ferguson  begins  his  incision  from  the  margin 
of  the  upper  lip,  carries  it  to  the  nostril,  and  along  the  ala 
to  within  half  an  inch  of  the  inner  canthus  ;  a  second  inci- 
sion extends  from  the  angle  of  the  mouth  to  the  zygomatic 
process,  and  a  third  at  right  angles  to  this  last^  extending 
from  the  external  angular  process  of  the  frontal  bone 
towards  the  neck  of  the  jaw.  Gensoul  lets  fall  a  vertical 
incision  from  near  the  inner  canthus,  and  divides  the  upper 
lip  entirely  tlirough  over  the  canine  tooth  ;  a  transverse  cut 


TREATMENT   OF  TUMORS,  AC.  635 

beginning  and  level  with  tlie  nostril,  extends  from  this  last 
to  the  forepart  of  the  lobe  of  the  ear.  A  third  incision 
commencing  about  half  an  inch  to  the  outer  side  of  the  ex- 
ternal canthus,  is  carried  down  almost  vertically,  and  touch- 
ing the  outer  extremity  of  the  transverse  incision.  Two 
flaps  are  thus  formed,  the  one  superior  and  dissected  up- 
wards, the  other  inferior  and  turned  downwards. 

Professor  Warren  and  M.  Velpeau  use  a  single  incision 
similar  in  shape,  and  extending  from  the  external  canthus, 
at  its  temporal  margin,  to  the  angle  of  the  mouth.  From 
this  incision  a  flap  is  dissected  upwards  from  the  surface  of 
the  bone,  the  ala  detached  from  the  nose,  and  the  whole 
turned  upwards  towards  the  forehead.  From  the  same  in- 
cision another  flap  is  turned  downwards  sufhciently  to  ex- 
pose the  malar  and  maxillary  bones. 

The  use  of  the  saw  and  cutting  forcejjs,  and,  if  necessary, 
the  chisel  and  mallet,  together  with  the  securing  of  the  ar- 
teries by  ligature,  and  the  actual  cautery — in  a  word,  the 
dressing  of  the  wound  in  all  these  different  methods  is 
nearly  the  same  as  that  already  described.* 

There  are  a  number  of  highly  interesting  cases  of  sarco- 
matous, carcinomatous,  and  other  tumors  of  the  maxillary 
sinus,  in  Jourdain's  Treatise  on  the  Surgical  Diseases  of  the 
Mouth  ;  some  of  Avhich  we  had  intended  to  introduce  into 
this  treatise,  but  apprehending  that  it  would  extend  it  to 
too  great  a  length,  we  have  concluded  to  omit  them.  A 
number  of  equally  interesting  cases  reported  in  various 
other  works, t  are  for  the  same  reason  excluded. 


*  Vide  liistou's  Practical  Surgery;  Ferguson's  I'ractical  Surgery;  Pancoast's 
Operative  Surgery  ;  Chflius'  System  of  Surgery,  and  Druit's  .Surgeon's  Vade 
Mecum. 

f  Vide  Journal  dc  Chirurgie,  torn,  i;  Parisian  Chirurgical  Journal,  torn,  i; 
CEuvrcs  Chir.  de  Desault,  par  Bichat,  torn,  ii;  New  London  Med.  Jour.  vol.  i; 
Eichorn.  Dis.  de  Polypis  in  antro  Ilighmori.  Trans,  of  the  Society  for  the  Im- 
provement of  Med.  and  Chir.  Knowledge.  Recuil  Periodique  de  la  Soc.  de  Med. 
torn,  ii ;  No.  9,  Edinburg  Med.  and  Chir.  Jour.  Nos.  83  and  84;  Traite  des  Mala- 
dies Chirurgicales,  tom.  iv;  Traite  des  Maladies  des  Fosses  Nazales;  New  York 
Jour,  of  Med.  and  Surgery;  Western  Lancet;  Cooper's  Surgical  dictionary; 
Benj.  Bell's  Surgery,  vol.  iv,  &c. 


636  TREATMENT   OF  TUMORS,  &C. 

In  conclusion,  we  would  remark,  tliat  Professor  Pattison 
proposed,  in  1820,  for  the  dispersion  of  fungous  tumors  of 
the  maxillary  sinus,  tying  the  carotid  artery.  He  was  in- 
duced to  recommend  this  method  of  treatment,  from  the 
consideration,  that  the  "capability  of  action  of  a  part,  is 
proportioned  to  its  vascularity,  and  that  thus  by  cutting  off 
the  circulation  of  blood  to  it,  the  morbid  growth  would 
slough  and  be  thrown  off.  He  says  this  practice  has  been 
successful  where  it  has  been  adopted  in  all  the  cases  that 
had  come  to  his  knowledge.* 

*  Vide  Appendix  of  Surgical  Anatomy  of  the  Head  and  Neck,  pp.  477-8. 


CHAPTER     EIGHTH. 

EXOSTOSIS  OF  THE  OSSEOUS  PARIETES  OF  THE  MAXIL- 
LARY smus. 

The  osseous  waUs  of  tlie  maxillary  sinus  sometimes  be- 
come the  seat  of  bony  tumors — a  disease  designated  by 
medical  writers  by  tbe  name  of  exostosis.  This,  however, 
is  not  an  affection  peculiar  to  the  bony  parietes  of  this  cavity  ; 
all  of  the  osseous  structures  of  the  body  are  liable  to  be  at- 
tacked by  it. 

Exostosis,  like  many  other  diseases,  present  several  va- 
rieties. It  is  divided,  by  some  writers,  into  true  and  false, 
the  one  consisting  of  a  tumor  composed  wholly  of  bone,  or 
nearly  so,  and  the  other,  of  a  tumor  composed  both  of  ossific 
matter  and  fungous  flesh,  or  of  a  mere  thickening  of  the 
periosteal  tissue.*  Sir  Astley  Cooper  divides  exostosis  into 
periosteal,  medullary,  cartilaginous  and  fungous.  The  first 
consists  of  a  deposition  of  bony  matter  on  ''the  external 
surface  of  a  bone  and  the  internal  surface  of  its  periosteum," 
and  to  both  of  which  it  firmly  adheres.  The  second  con- 
sists of  ""a  similar  formation,  originating  in  the  medullary 
membrane  and  cancellated  structure  of  the  bone,"  this  dis- 
crij)tion  of  exostosis  never  attacks  the  walls  of  the  maxillary 
sinus.  By  cartilaginous  exostosis  he  means,  ''that  which  is 
preceded  by  the  formation  of  cartilage,  which  forms  the 
nidus  for  the  ossific  deposit."  Fungous  exostosis  he  des- 
cribes to  be  a  tumor  not  so  firm  in  its  consistence  as  carti- 
lage, but  harder  than  fungous  flesh,  having  interspersed 
through  its  substances  spicula  of  bone,  of  a  malignant  char- 

*.  Vide  Dictionnaire  des  Sciences  Medicales,  t.  xvi,  p.  218. 


638  EXOSTOSIS   OF   THE  WALLS   OF   THE    ANTRUM, 

acter,  and  dependent  upon  some  peculiar  constitutional 
diathesis,  and  action  of  vessels.  This  species  of  exostosis 
differs  but  little,  if  at  all,  from  osteo-sarcoma. 

Exostoses  differ  as  much  in  shape  as  they  do  in  structure. 
They  sometimes  rise  abruptly  from  the  surface  of  bones  by 
a  narrow  and  circumscribed  base,  projecting  in  large  irregu- 
larly or  spherically  shaped  masses  ;  at  other  times  they  rise 
very  gradually,  covering  a  larger  surface  of  the  affected 
bone,  but  less  massy  and  with  limits  less  perfectly  defined. 
An  exostosis  has  been  known  to  occupy  the  whole  extent  of 
the  surface  of  a  bone.  "The  whole  external  surface  of  one 
of  the  bones  of  the  skull  was  found  occupied  by  an  exostosis, 
while  the  cerebral  surface  of  the  same  bone  was  in  a  natural 
state.*  Both  sides  and  the  whole  thickness  of  bones  are 
occasionally  affected  by  this  disease.  This  is  what  Sir  Ast- 
ley  Cooper  calls  periosteal  exostosis. 

This  disease  is  said  to  attack  some  bones  more  frequently 
than  others.  Those  of  the  skull,  the  lower  jaw,  sternnm, 
humerus,  radius  ulna,  femur,  tibia  and  bones  of  the  carpus 
are  the  most  subject  to  it.  It  also  very  frequently  attacks, 
the  upper  jaw,  and  none  of  the  bones  of  the  body,  in  fact, 
are  exempt  from  it. 

The  texture  of  exostosis  is  sometimes  spongy  and  cellular, 
at  other  times,  very  dense.  Dr.  E.  Carmichael,  a  distin- 
guished surgeon  and  physician,  formerly  of  Fredericksburg, 
Virginia,  described  to  the  writer,  a  few  years  since,  an  exos- 
tosis of  the  superior  maxillary,  which  had,  a  short  time 
before,  fallen  under  his  observation,  larger  than  a  hen's 
egg,  and  as  solid  as  ivoiy.  Exostosis  of  the  roots  of  the 
teeth  are  always  hard,  and  instances  are  sometimes  met  with 
of  osseous  tumors  upon  other  bones  possessed  of  nearly  an 
equal  degree  of  solidity.  Exostoses  of  this  description  grow 
less  rapidly  than  those  which  are  more  cellular  ;  but  they 
sometimes  acquire  a  very  large  size.     It  is  not,  however, 

*  Vide  American  edition  of  Cooper's  Surgical  Dictionary,  p.  362. 


EXOSTOSIS   OF   THE   WALLS   OF    THE   ANTRUM.  639 

uncommon  for  such,  after  having  attained  a  greater  or  less 
size,  to  cease  to  grow,  and  "remain  stationary''  through, 
life,  without  giving  rise  to  any  very  serious  or  unpleasant 
consequences. 

Exostoses  sometimes  attain  an  enormous  size,  and  espe- 
cially upon  cylindrical  bones  ;  very  large  ones,  too,  are  fre- 
quently met  with  upon  the  maxillse.  The  largest  one,  we 
believe,  of  the  maxillary  sinus,  of  which  medical  history 
furnishes  any  account,  is  exhibited  upon  a  specimen  of 
morbid  anatomy,  presented  in  1767,  by  M.  Beaupreau,  to 
the  French  Academy.  A  description  and  Jiawiug  of  this 
tumor  is  contained  in  the  Memoirs  of  the  Royal  Academy  of 
Surgery,  but  we  have  no  account  of  the  history  of  its  forma- 
tion, nor  of  the  symptoms  that  resulted  from  it.  The  tumor 
occupies  the  whole  of  the  right  maxillary  sinus,  and  several 
of  the  neighboring  bones  are  involved  in  it.  It  is  very  large 
near  its  base  and  projects  from  the  lower  part  of  the  orbit, 
forward  and  downward,  six  inches.  Its  largest  circumfer- 
ence is  said  to  be  one  foot.  The  upper  part  of  the  maxillary 
bone,  says  Bordenave,  projects  on  the  side  of  the  orbit,  and 
straightens  the  oavity  ;  the  os  unguis  is  included  in  the  mass 
of  the  tumor,  and  is  represented  as  being  nearly  effaced. 
The  nasal  bones  of  the  left  side  are  displaced,  and  the  right 
nostril  entirely  closed  up,  and  the  exostosis  projects  so  much, 
on  the  left  side  as  to  be  nearly  underneath  the  malar  bone. 
The  inferior  part  of  the  maxillary  bone,  says  our  author^  is 
so  extended  near  its  base,  that  it  inclines  obliquely  to  the 
left,  and  the  pterygoid  apophyses  of  this  side  are  larger  than 
those  of  the  other.  The  malar  bone  is  described  as  beins; 
involved  in  the  upper  and  external  part  of  the  exostosis, 
which  extends  to  the  left  maxillary  bone. 

Exteriorly,  says  Bordenave,  the  tumor  had  a  smooth  and 
polished  appearance,  its  upper  part  was  very  hard  ;  infe- 
riorly  its  substance  had  become  thinner,  was  wanting  in 
some  places,  and  the  interior  of  the  exostosis  was  exposed. 
The  substance  of  the  bone  was  spongy  and  porous,  and  in 


640  SYMPTOMS   OF   EXOSTOSIS. 

appearance,  not  unlike  pumice  stone.  The  walls  were  thick, 
and  measured  in  some  places  one  inch.* 

From  this  brief  description,  taken  from  one  given  of  it 
by  Bordenave,  some  idea  may  be  formed  of  the  dimensions 
and  appearance  of  this  enormous  and  most  remarkable 
exostosis. 

A  case  of  exostosis  of  each  antrum,  is  described  by  Sir 
Astley  Cooper,  both  of  which  forced  themselves  up  into  the 
orbits,  and  pushed  the  eyes  from  their  sockets.  One  made 
its  way  into  the  brain,  and  caused  the  death  of  the  patient. f 

Mr.  Thomas  Bell  does  not  believe  in  the  occurrence  of 
''Hrue  exostosis  upon  the  bony  parietes"  of  this  cavity,  but 
too  many  examples  have  presented  themselves,  to  leave  any 
room  for  doubt  upon  the  subject.  Although  none  may  ever 
have  fallen  under  his  own  immediate  observation,  there  are 
many  well  authenticated  cases  on  record — the  details  of 
some  of  which  we  shall  presently  give.  Apart  from  these, 
we  think  it  would  be  difficult  to  assign  any  sound  reasons 
for  supposing  that  the  osseous  walls  of  this  cavity  should 
be  more  exempt  from  the  disease  than  other  bones  of  the 
body. 

SYMPTOMS. 

The  attacks  of  exostosis  of  the  walls  of  the  maxillary 
sinus,  are  generally  so  insidious,  that  the  presence  of  the 
disease  is  not,  for  a  long  time,  even  suspected.  When  it 
results  from  venereal  vice,  Boyer  says,  it  is  preceded  by 
acute  pain,  extending  at  first  to  almost  every  part  of  the 
affected  bone,  but  which  afterwards  confines  itself  to  the 
afiected  portion.  When  it  is  occasioned  by  scrofula,  the 
same  writer  tells  us,  it  is  attended  by  a  duller  and  less 
severe  pain  ;  the  symptoms  of  exostosis  resulting  from 
causes  purely  local,  such,  for  example,  as  a  blow,  are  very 
similar. J     These  signs  are  common  to  the  disease  wherever 

*  Vide  Memoires  de  rAcademie  Royale  de  Chirurg.,  t.  xiii,  obs.  xii,  p.  412. 

t  Surgical  Essays,  part  i,  p.  157. 

:j:  Traite  des  Maladies  Chirurgicales,  t.  iii,  p.  545. 


TREATMENT   OF   EXOSTOSIS.  641 

it  may  be  situated,  and  when  it  is  seated  in  tlie  maxillary 
sinus,  tliey  do  not  distinguish  it  from  many  of  the  other 
affections  that  occur  here  ;  for  they  are  often  produced  by 
them,  as  well  as  by  exostosis.  Furthermore,  the  disease  not 
unfrequently  gives  rise  to  other  symptoms  attendant  upon 
several  of  the  other  affections  of  this  cavity,  so  that  pre- 
viously to  the  distension  of  its  walls,  it  may  be  confounded 
with  inflammation  of  the  lining  membrane  or  sarcomatous 
or  other  tumors.  After  it  has  filled  the  sinus,  or  very  con- 
siderably thickened  its  exterior  walls,  it  will  cause  them  to 
offer  a  firmer  resistance  to  pressure  than  any  of  the  other 
diseases  of  this  cavity.  When,  therefore,  they  have  become 
distended,  if  they  are  firm  and  unyielding  .to  pressure,  the 
presence  of  exostosis  may  be  inferred. 

CAUSES. 

There  is  a  difference  of  opinion  among  writers  on  the  dis- 
eases of  bones,  with  regard  to  the  causes  of  exostosis.  Cer- 
tain constitutional  diseases,  such  as  "'^scrofula  and  lues 
venerea/'  are  thought  by  some  to  give  rise  to  t'  o  affection. 
That  the  last  of  these  diseases  is  favorable  to  its  production, 
is,  we  believe,  admitted  by  all ;  but  Sir  Astley  Cooper  de- 
clares that  no  evidence  has  yet  been  adduced  to  prove  that 
the  former  is  ever  concerned  in  its  production.  Others  im- 
pute the  disease  to  local  irritation  produced  by  contusions, 
fractures,  &c.  It  is  probably  dependent  upon  both  local 
and  constitutional  causes,  and  that  neither,  independently 
of  the  other,  is  capable  of  producing  it. 

T  R  E  A  T  M  E  iN  T  . 

A  variety  of  plans  of  treatment  liave  been  recommended 
for  this  disease,  and  Bordenave  assures  us  it  may  be  cured, 
if  suitable  remedies  are  applied  before  it  lias  acquired  much 
solidity.     Assuming  that  it  sometimes  results  from  consti-. 
tutional  causes,   lie  directs  that  the  treatment  should  be 


642  TREATMENT   OF   EXOSTOSIS. 

commenced  Ly  the  employment  of  such  means  as  are  indi- 
cated by  the  nature  of  the  vice  with  which  the  patient  may 
be  affected.  If  a  venereal  vice  be  present,  the  use  of  mer- 
curial medicines  are  recommended.  The  author  last  men- 
tioned, says,  he  has  known  it  to  be  successfully  treated  with 
mercury.  Topical  applications,  such  as  fomentations  and 
cataplasms,  have  also  been  found  serviceable.  Boyer  ad- 
vises poultices  of  linseed  meal,  and  a  decoction  of  the  "leaves 
of  henbane  and  nightshade."  Iodine  and  mercury  have 
been  employed,  but  not,  we  believe,  with  any  decided  ad- 
vantage. Sir  Astley  Cooper  thinks  the  best  internal  remedy 
is  "oxymuriate  of  quicksilver,  together  with  the  compound 
decoction  of  sarsaparilla."  We  believe,  with  Boyer,  that  a 
dispersion  of  an  exostosis  can  never  be  effected.  Its  pro- 
gress may,  perhaps,  be  partially  arrested,  but  we  do  not  be- 
lieve, that  it  is  ever  taken  up  by  the  absorbents.  It  is  not 
advisable  to  remove  an  exostosis  unless  it  continues  to  aug- 
ment and  is  likely  to  become  dangerous,  or  is  productive  of 
serious  inconvenience. 

When,  therefore^  the  remedies  which  have  been  men- 
tioned, after  having  been  thoroughly  tried,  prove  unsuccess- 
ful, the  tumor  should  be  fully  exposed ;  first,  by  the  dissec- 
tion of  the  gum  and  other  soft  parts  from  the  exterior  walls 
of  the  sinus,  and,  second,  by  the  perforation  of  this  cavity 
with  a  trephine,  or  such  other  instrument  as  can  be  most 
conveniently  employed.  This  part  of  the  operation,  though 
simple,  should  be  conducted  with  care.  If  the  tumor  is 
large  and  attached  by  a  very  broad  base,  its  removal  will 
sometimes  prove  more  difficult,  yet  by  means  of  suitable 
constructed  saws,  scissors,  knives,  &c.,  it  may,  in  most  in- 
stances, be  easily  effected.  An  external  wound  through  the 
cheek  should  always,  if  possible,  be  avoided. 

The  method  of  operating,  however,  will  be  best  under- 
stood by  a  description  of  that  pursued  in  the  two  following 
cases.  The  first  was  treated  by  Dr.  B.  A.  Rodrigues,  den- 
tist, of  Charleston,  S.  C,  and  reported  by  him  for  the 
American  Journal  of  Medical  Sciences. 


TREATMENT   OF   EXOSTOSIS.  643 

Case  21st.  '^On  the  14tli  of  August,  1837,  Charity,  a 
servant  woman  of  Mrs.  Miller,  called  on  me  to  ascertain 
whether  I  could  afford  her  any  relief  in  her  wretched  con- 
dition. She  had  been  laboring  under  incessant  and  ago- 
nizing pain  in  the  antrum  highmorianum  of  the  right  side, 
which  she  regarded  as  the  consequence  of  the  impaired  con- 
dition of  the  teeth.  On  this  supposition,  she  had  several 
of  them  extracted,  without  any  appreciable  abatement  of 
her  sufferings.  Yet,  deluded  with  the  belief  that  some  one 
of  the  remaining  teeth  was  the  secret  agent  of  all  she  suf- 
fered, she  persisted  in  having  more  extracted.  Still,  the 
evil  continued,  the  suffering  was  unabated,  the  cause  unde- 
tected; and  to  add  to  the  depression  of  her  hopes,  and  the 
aggravation  of  her  ills,  a  purulent  discharge  oozed  from  the 
empty  sockets  of  the  affected  side.  She  again  had  recourse 
to  medical  advice,  hoping  that  this  phasis  of  her  malady 
might  lead  to  some  indications  that  would  relieve  her ;  at 
least,  that  it  might  reveal  its  hidden  sources,  its  condition, 
and  its  prospects  of  being  remediable.  And  here,  for  the 
first  time,  was  it  suggested  that  the  antrum  was  in  an  un- 
sound state. 

"It  was  at  this  moment,  under  these  circumstances,  that 
she  applied  to  me  to  perform  an  operation,  which  her  medi- 
cal adviser  declared  to  be  indispensable.  At  first,  I  im- 
agined it  to  be  an  abscess  from  the  cavity  from  which  the 
pus  was  discharged,  from  the  strange  sensations  experienced, 
and  from  the  greater  frequency  of  this  disease  over  others 
peculiar  to  this  part,  I  inserted  a  trocar  into  the  socket  of 
the  second  molar,  and  instead  of  the  gush  of  matter  I  had 
expected,  the  passage  of  the  instrument  was  intercepted  by 
a  hard,  dense,  impregnable  substance.  The  existence  of  an 
exostosis  now  forced  itself  on  me.  To  make  assurance 
doubly  sure,  I  had  access  to  several  of  my  medical  friends, 
among  whom  was  Dr.  Geddings.  On  examination  of  the 
part,  the  consideration  of  the  symptoms,  the  obstinate  na- 
ture of  the  disease,  they  concurred  with  me  in  opinion,  that 
an  exostosis  was  present,  and  that  the  sole  indication  of  re- 


644  TREATMENT   OF   EXOSTOSIS. 

lief  was  its  extirpation.  Accordingly,  on  the  ISth  of  Au- 
gust, the  above  gentlemen,  with  several  others  of  the  pro- 
fession, were  present  when  I  proceeded  to  perform  the  ope- 
ration. With  a  common  scalpel,  I  dissected  away  the  gum 
from  ihe  canine  tooth  to  the  last  molar,  raised  the  flap 
which  it  made  from  the  alveolar  process,  and  with  a  tre- 
phine opened  into  the  cavity.  Success  Avas  easier  than  had 
been  anticipated,  in  consequence  of  the  carious  condition  of 
the  process,  which  was  so  general  on  the  affected  side,  as  to 
reach  from  the  second  incisor  anteriorly  to  the  pterygoid 
process  posteriorly.  In  the  loss  of  substance,  the  external 
jiarietes  of  the  cavity  shared,  so  that  the  bony  tumor  which 
filled  up  and  occupied  it,  could  be  readily  reached.  The 
trephine  was  applied,  the  cavity  enlarged,  and  the  exostosis 
removed.  It  measured  in  circumference  three  inches,  was 
light,  and  cancellated  on  its  surface,  but  dense  and  more 
resisting  in  its  more  internal  layers.  There  was  little  or 
no  hemorrhage  to  delay  the  operation,  or  any  application  to 
arrest  it.  After  removing  every  spiculum  of  diseased  bone, 
and  cleansing  out  the  cavity,  the  flap  was  replaced,  and  to 
nature  was  entrusted  the  cure.  Granulations  sprouted  up 
in  full  luxuriance,  and  in  the  short  period  of  four  weeks^ 
the  woman  was  in  the  enjoyment  of  excellent  health."* 

That  the  foregoing  was  a  case  of  true  exostosis  of  the 
maxillary  sinus,  does  not  admit  of  doubt,  and  it  is  to  be 
regretted,  that  more  of  the  early  history  of  the  disease,  and 
the  circumstances  connected  with  its  developments,  are  not 
known.  They  might,  perhaps,  lead  to  a  correct  explanation 
of  the  causes  that  gave  rise  to  it.  The  presence  of  local 
irritants  in  the  immediate  vicinity  of  this  cavity,  is  proven 
by  the  fact  that  the  patient's  teetli  were  in  a  diseased  con- 
dition, but  to  what  extent  they  may  have  contributed  to  the 
production  of  the  exostosis  it  is  impossible  to  determine, 
since  we  are  not  furnished  with  any  information  concerning 
the  state  of  her  general  health.  She  may  have  been  afiect- 
ed  with  some  constitutional  vice,  or  peculiar  habit  of  body, 

*  American  Journal  of  Medical  Science. 


TREATMENT   OF   EXOSTOSIS.  645 

wliereby  the  osseous  structures  of  the  system  were  predis- 
posed to  affections  of  this  description^  requiring  only  the 
presence  of  some  local  irritant  to  induce  the  morbid  action 
necessary  to  their  development.  That  such  predisposition 
did  exist,  and  that  such  action  was  excited  by  the  irritation 
produced  by  the  diseased  teeth,  we  believe,  would  appear,  if 
all  the  circumstances  connected  with  the  previous  history  of 
the  case  could  be  ascertained. 

When  the  connection  of  the  exostosis  is  such  as  to  prevent 
its  complete  removal,  the  application  of  the  actual  cautery 
to  any  remaining  portions,  will  prove  serviceable,  by  caus- 
ing such  parts  to  be  exfoliated.  The  history  of  a  case  is 
related  by  M.  Bordenave,  treated  by  M.  Kunge,  in  which  a 
portion  of  the  exostosis  was  left,  and  which  ultimately 
caused  the  death  of  the  patient.  This  would  probably  have 
been  prevented  had  an  exfoliation  of  the  remaining  dis- 
eased portions  of  bone  been  brought  about  by  an  application 
of  the  actual  cautery. 

Case  22nd.*  The  subject  of  this  case  was  a  man  33  years 
of  age.  He  had  been  for  a  long  time  afflicted  with  a  tumor 
in  the  region  of  the  right  antrum.  It  depressed  the  palatine 
process  of  the  maxillary  bone  and  the  palate  bone  of  the  af- 
fected side  in  such  a  manner  as  to  restrict  the  movements  of 
the  tongue,  while  on  the  other  side  it  pressed  against  the 
floor  of  the  orbit  so  as  to  cause  a  protrusion  of  the  eye. 
Anteriorly,  it  had  elevated  a  portion  of  the  maxillary  and 
malar  bones  which  covered  it,  and  extended  to  the  most  de- 
pendent part  of  the  nose,  whilst  posteriorly  it  extended  as 
far  as  the  posterior  mouth.  Its  effects  upon  the  lateral 
parts  were  nearly  the  same  as  those  which  it  had  exerted 
upon  the  others. 

After  having  exposed  the  anterior  parietes  of  the  antrum, 
M.  David  saw  from  below  upwards  to  the  uppermost  part  of 
the  projection  of  the  tumor,  which  was  of  spherical  shape, 
and  nearly  three  inches  in  diameter,  and,  after  having  ele- 
vated that  part,  he  discovered  the  tumor,  which  was  white 

*  Vide  Memoires  do  I'Academie  Royale  de  Chirurg.  t.  xiii,  obs.  xi,  p.  408. 


646  TREATMENT   OF   EXOSTOSIS. 

and  hard  ;  although  spongy,  and  bearing  a  strong  resem- 
blance to  soft  agaric,  it  occupied  the  maxillary  sinus.  It 
had  changed  the  form  of  this  cavity  and  increased  its  di- 
mensions to  an  extraordinary  degree.  The  greater  portion 
of  this  hard  osseous  substance,  although  firmly  adhering  to 
almost  every  part  of  its  bony  envelop,  was  by  a  persevering 
employment  of  various  means^,  such  as  the  crotchet,  eleva- 
tor, surgeon's  rasp,  &c.,  detached  by  M.  David.  In  doing 
this,  he  inflicted  some  iujury  upon  the  floor  of  the  orbit, 
and  to  some  portions  which  still  adhered  to  the  palatine 
process  of  the  maxillary  bone,  he  applied  the  actual  cau- 
tery, wliich  was  repeated  several  times. 

An  opening  was  formed  by  this  operation  four  and  a  half 
inches  deep,  and  from  right  to  left,  of  more  than  three 
inches,  but  a  cure  was,  notwithstanding,  speedily  effected 
by  it,  which,  had  the  use  of  the  cautery  been  omitted,  would 
not  perhaps  have  been  successful. 

Exostosis  of  the  maxillary  sinus  often  gives  rise  to  other 
morbid  conditions  of  this  cavity,  the  remedial  indications  of 
which  should  be  properly  attended  to,  as  should  also  those 
of  any  constitutional  affection,  vice^  or  habit  of  body  that 
the  patient  may  be  laboring  under  at  the  time. 

When  the  exostosis  is  not  complicated  with  any  other  dis- 
ease of  the  cavity,  the  restorative  energies  of  nature,  after 
its  removal,  will  generally  be  all  that  is  required  to  com- 
plete the  cure. 


CHAPTER      NINTH. 

WOUNDS   OF    THE  OSSEOUS    PARIETES   OF    THE   MAX- 
ILLARY SINUS. 

The  waUs  of  the  maxillary  sinus  are  sometimes  fractured 
by  blows  and  pierced  by  sharp-pointed  instruments.  Fau- 
chard  mentions  a  case,  in  which  a  canine  tooth  had  been 
driven  up  into  it.*  This  is  an  accident  that  rarely  happens. 
The  instance  here  alluded  to,  is,  we  believe,  the  only  one  on 
record ;  and,  as  might  be  suj)posed_,  it  was  followed  by 
severe  pain,  and  ultimately  gave  rise  to  a  tumor  upon  the 
cheek  near  the  nose,  and  three  fistulous  openings,  from 
which  fetid  matter  was  discharged.  The  sinus  having  been 
opened,  and  the  tooth  taken  from  it,  a  cure  was  at  once 
effected. 

It  often  happens  when  the  walls  of  the  sinus  are  fractured 
from  a  blow  or  other  mechanical  violence,  that  portions  of 
the  bone  and  foreign  bodies  are  driven  into  the  cavity,  and 
which,  remaining  there,  become  a  constant  source  of  irrita- 
tion to  the  lining  membrane,  and,  not  unfrequently,  a  hid- 
den cause  of  other  and  more  malignant  forms  of  disease. 
Bordenave  describes  the  case  of  a  French  officer,  who  had 
the  walls  of  the  maxillary  sinus  fractured  by  a  fragment  of 
a  bomb.  Dressings  were  applied  to  the  wound,  but  it  did 
not  heal,  and  upon  examination  sometime  after  by  M. 
Allouel,  several  pieces  of  bone  and  a  splint  which  nearly 
filled  the  cavity  were  found.  These  were  removed,  but  a 
cure  was  not  immediately  effected;  a  fistulous  opening  still 
remained,  and  it  was  not  until  a  long  time  after,  when 

*  Le  Chirurgien  Dentiste,  torn,  i,  page  391. 


648       TREATMENT  OF  WOUNDS  OF  THE  ANTRUM. 

anotlier  splinter  came  away,  tliat  the  external  opening 
healed.  The  same  writer  mentions  the  case  of  a  man  who 
had  a  nail  forced  head  foremost,  by  the  discharge  of  a  gun, 
into  his  right  cheek  and  maxillary  sinus.  The  opening  be- 
came fistulous,  and  although  the  point  of  the  nail  was  sub- 
sequently discharged,  it  was  not  until  M.  Faubert  had  re- 
moved the  remaining  part,  that  the  fistula  closed. 

Wounds  of  the  antrum  are  almost  always  complicated 
with  fractures  of  the  osseous  parietes,  so  that  the  efiects  re- 
sulting from  them  are  more  to  be  dreaded  than  those  which 
would  be  produced  simply  by  the  penetration  of  a  sharp  in- 
strument. 

TREATMENT. 

The  nature  and  extent  of  the  injury  inflicted,  should  de- 
termine the  treatment  most  proper  to  be  adopted  for  wounds 
of  this  cavity.  Complicated  as  they  in  most  instances  are 
by  the  presence  of  extraneous  substances,  the  removal  of 
these  constitutes  the  first,  and  not  unfrequently,  the  only 
remedial  indication.  This  should  never  be  neglected. 
When  any  extraneous  bodies,  or  portions  of  bone,  have  been 
forced  into  the  sinus,  they  should  first  be  all  carefully  re- 
moved. The  external  wound  may  next  be  dressed  with  ad- 
hesive slips  to  prevent  the  formation  of  an  unsightly 
cicatrix.  If  constitutional  symptoms  supervene,  they  should 
be  met  with  appropriate  remedies. 

The  following  interesting  case  of  a  wound  of  the  maxilla- 
ry sinus,  inflicted  witli  a  dirk -knife,  reported  by  R.  S.  Wel- 
den,  student  of  medicine,  and  treated  by  W.  H.  Donne, 
M.  D.,  of  Louisville,  Ky.,  is  taken  from  the  Western  Jour- 
nal of  Medicine  and  Surgery. 

Case  23d.  ''Schuti,  a  gardener,  aged  42  years,  a  native 
of  Germany,  in  a  rencontre  with  an  athletic  man,  on  the  3d 
of  May,  1840,  Avas  struck  with  a  dirk-knife,  which  enter- 
ed about  an  inch  above  the  right  superciliary  arch,    passed 


TREATMENT  OF  WOUNDS  OF  THE  ANTRUM.       649 

through  the  corresponding  eyelid  downwards  and  back- 
wards, evacuating  the  humors  of  the  eye,  and  penetrating 
the  antrum.  The  globe  of  the  eye  was  divided  by  a  vertical 
incision,  through  which  the  aqueous  humor  escaped ;  the  iris 
was  extensively  detached  at  the  ciliary  margin,  and  could  be 
partially  seen  through  the  transparent  cormea — its  surface 
being  somewhat  obscured  by  small  coagula.  The  hemorr- 
hage was  slight  and  easily  controlled  by  moderate  pressure. 
The  patient  complained  of  intense  pain  in  the  temple  and 
cheek  of  the  wounded  side  shooting  deep  into  the  orbit. 
Three  points  of  interrupted  suture  were  used  to  approx- 
imate the  edges  of  the  divided  eye.  Lint,  saturated  with 
laudanum  and  warm  water,  constituted  the  dressing. 

"May  4th.  Some  tumefaction  in  the  eyelid  ;  pulse  110  ; 
tongue  coated  and  dry  ;  skin  hot ;  patient  had  spent  a  very 
restless  night.  Ordered  following  medicine,  tart,  emetic, 
gr.  i.;  sulph.  magnesia,  |ss.;  to  be  dissolved  in  one-half 
pint  of  water,  and  a  table-spoonful  to  be  taken  every  half- 
hour,  until  nausea  is  induced — after  which  the  interval  may 
be  increased. 

"May  5th.  Bowels  freely  evacuated  ;  pain  less  ;  skin 
moist ;  pulse  90  and  soft.  From  this  period  until  the 
wound  healed — the  space  of  three  weeks — no  constitutional 
symptoms  of  an  untoward  character  occurred.  The  patient^ 
however,  contended  that  a  portion  of  the  knife-blade  re- 
mained in  the  roof  of  his  mouth.  But,  on  the  most  careful 
examination,  no  foreign  body  could  be  detected. 

"On  the  10th  of  August,  1842,  Mr.  Schuti  called  and  re- 
quested Dr.  Donne  to  examine  his  mouth,  stating  that  for 
six  months  past  he  had  been  annoyed  by  a  rough,  projecting 
substance,  which  some  person  had  informed  him  was  a  piece 
of  dead  bone,  but  which  he  believed  to  be  the  point  of  the 
knife,  that  had  been  driven  down  into  the  bone  by  the  vio- 
lence of  the  blow.  On  looking  into  the  mouth,  a  small 
black  speck  was  discernable  about  one-half  inch  from  the  in- 
terval between  the  first  and  second  molar  teeth.  The  parts 
adjacent  were  somewhat  tumefied  and  inflamed.  Dr.  Don- 
42 


650       TREATMENT  OF  WOUNDS  OF  THE  ANTRUM. 

ne  made  several  attempts  to  extract  this  body  with  a  pair 
of  common  dissecting  forceps^  but  found  it  immovably  fixed 
in  the  substance  of  the  bone.  By  dissecting  around  it  with 
a  bistoury,  down  to  the  palate  process  of  the  superior  max- 
illary bone,  he  was  enabled  to  get  a  firmer  hold,  and,  with 
a  pair  of  curved  tooth-forceps,  succeeded  in  removing  a  frag- 
ment of  the  blade,  one  and  one-fourth  inches  in  length,  and 
three-fourths  in  width  at  the  widest  part ;  the  extraction 
was  not  efiected  without  considerable  violence,  and  was  at- 
tended with  extreme  suffering.  The  fragment  came  out 
with  an  audible  snap_,  which  induced  those  present  to  sup- 
pose^ at  first,  that  it  had  been  broken  ;  but  on  inspecting 
its  surfaces  closely,  they  were  found  similarly  oxydized,  and 
wanting  the  lustre  which  a  recent  fracture  had  presented. 
Upon  probing  the  aperture,  through  which  the  fragment 
had  been  extracted,  no  other  piece  could  be  detected.  This 
opening  would  scarcely  admit  the  curved  probe  which  Dr. 
Donne  passed  into  the  antrum,  in  order  to  satisfy  himself, 
that  the  whole  of  the  foreign  body  was  removed.  The  next 
day  there  was  a  slight  discharge  from  the  aperture,  though 
the  patient  has  suffered  very  little  pain  since  the  opera- 
tion." 

The  foregoing  is  certainly  one  of  the  most  singular  cases 
of  which  we  have  any  account,  and  the  most  remarkable 
circumstance  connected  with  it  is_,  that  no  more  injury 
should  have  resulted  from  the  presence,  for  so  long  a  time, 
in  the  maxillary  sinus,  of  the  portion  of  the  blade  of  the 
knife  that  had  been  broken  off.  In  the  cases  previously 
noticed,  as  reported  by  Bordenave,  disease  of  the  mucous 
membrane  of  the  antrum,  and  the  discharge  of  fetid  sanies 
resulted  from  the  presence  of  the  foreign  bodies  in  this  cav- 
ity. The  same  effects  were  also  produced  in  the  case  describ- 
ed by  Fauchard,  of  the  canine  tooth  which  had  been  forced 
up  into  the  antrum. 


CHAPTER      TENTH. 

FOREIGN  BODIES  IN  THE  MAXILLARY   SINUS. 

That  foreign  bodies  are  sometimes  admitted  into  the 
maxillary  sinus  through  wounds  penetrating  its  exterior 
parietes,  has  already  been  shown,  but  that  they  should  gain 
access  to  it  in  any  other  way^  would  seem  almost  impossible. 
The  smalluess  and  peculiar  situation  of  the  opening  which 
communicates  with  it,  is  such,  one  would  think,  as  would 
preclude  the  introduction  of  extraneous  substances  of  any 
kind  through  it,  yet  they  have  been  found  here  when  they 
could  not  have  gained  admission  in  any  other  way.  There 
are  several  well  authenticated  cases  on  record  in  which 
worms  have  been  found  in  this  cavity.  The  case  mention- 
ed by  Bordenave,  in  the  Memoirs  of  the  Royal  Academy, 
of  a  diseased  maxillary  sinus,  from  wlfich  several  worms 
were  at  different  times  discharged,  does  not  prove  that  they 
obtained  admission  into  it  through  the  nasal  opening,  and 
thus,  as  some  writers  have  conjectured,  gave  rise  to  the 
disease  with  which  it  was  affected.  In  this  case,  a  fistulous 
opening  from  the  cavity  had  existed  for  a  long  time  pre- 
viously to  the  discharge  of  the  worms_,  and  it  is  very  prob- 
able that  they  introduced  themselves  through  this  open- 
ing. A  cause  sufficient  to  have  produced  the  disease  in  the 
sinus  had  been  operating  for  two  years,  immediately  preced- 
ing its  manifestation.  The  patient,,  during  the  whole  of 
this  time,  was  affected  with  pain  in  the  superior  teeth  of 
the  affected  side. 

Deschamps,  says  his  colleague  of  la  Charite  Hospital, 


652  SYMPTOMS   OF   FOREIGN   BODIES  IN  THE   ANTRUM. 

found  a  worm  in  the  maxillary  sinus  of  a  soldier,  whom  he 
was  dissecting^  four  inches  long  ;  and  the  same  writer  in- 
forms us  that  a  similar  example  is  furnished  in  the  Journal 
of  Medicine.  The  particulars  of  a  case  which  came  under 
the  observation  of  Mr.  Heysham,  physician,  of  Carlisle^ 
taken  from  a  work  entitled  "Medical  Commentaries,"  are 
contained  in  Cooper's  Surgical  Dictionary.  The  subject  of 
this  case  was  a  strong  woman,  sixty  years  of  age,  who  was 
in  the  habit  of  taking  a  great  deal  of  snuff.  She  was  affect- 
ed for  a  number  of  years  with  severe  pain  in  the  region  of 
the  maxillary  sinus,  which  "extended  over  one  side  of  the 
head."  She  was  never  entirely  free  from  this  pain,  but  it 
was  greater  in  cold  than  in  warm  weather,  and  for  the  pur- 
pose of  obtaining  relief,  she  had  been  twice  salivated,  and 
had  taken  various  anodyne  medicines.  The  pain,  however, 
instead  of  being  mitigated  by  these  means,  became  more 
severe.  Her  teeth  on  the  affected  side  were  all  extracted, 
and  as  a  last  resort  the  maxillary  sinus  was  perforated. 
This  for  several  days  did  not  give  any  relief.  Injections  of 
bark  and  "elixir  of  aloes,"  were  thrown  into  it,  and  "on 
the  fifth  day  a  dead  insect"  of  more  than  an  inch  in  length 
and  as  thick  as  a  "common  quill,"  was  removed  from  this 
cavity. 

Instances  of  the  introduction  of  insects  or  foreign  bodies 
of  any  descrij)tion  into  the  antrum,  through  the  nasal  open- 
ing, fortunately,  are  so  exceedingly  rare,  that  the  Memoirs 
of  Medicine  do  not  furnish  more  than  four  or  five  well  estab- 
lished examples. 

The  signs  indicative  of  the  presence  of  insects  or  foreign 
bodies  in  the  maxillary  sinus,  are  so  obscure,  that  the  fact 
can  only  be  ascertained  by  perforating  the  cavity  and  by 
examination  of  its  interior.  Some  say  that  foreign  bodies 
here  cause  an  itching,  crawling  or  tickling  sensation  in  the 
substance  of  the  cheek.  This  is  an  uncertain  diagnosis,  for 
such  sensations  are  not  unfrequent  in  the  region  of  this 
cavity.     That  they  sometimes  cause  great  pain,  is  proven 


SYMPTOMS   OF   FOREIGN  BODIES  IN   THE  ANTRUM.  653 

by  the  history  of  the  case  related  by  Mr.  Heysham,  the  par- 
ticulars of  which  we  have  just  noticed. 

The  proper  remedial  indication  for  foreign  bodies  in  the 
antrum,  is  their  removal.  When  insects  are  discovered 
here,  injections  of  oil  and  tepid  water  are  recommended. 
This  constitutes  all  the  treatment  necessary  to  be  employed 
in  cases  of  this  kind. 


PA.RT    SIXTH 


MECHANICAL   DENTISTRY. 


I>A^RT     SIXTH. 


MECHANICAL    DENTISTRY. 

By  meclianical  dentistry  is  meant  the  art  of  constructing 
and  applying  artificial  teeth,  artificial  palates,  and  appli- 
ances/or the  correction  of  irregularity  in  the  arrangement  of 
the  natwal  teeth.  But  in  treating  upon  this  part  of  our  sub- 
ject^ we  shallj  for  the  present,  confine  ourself  to  the  first,  or 
a  description  of  the  various  methods  of  constructing  and 
applying  artificial  teeth,  reserving  what  we  may  have  to 
say  upon  artificial  obturators  and  palates  for  the  seventh 
and  last  part  of  our  work,  and  as  the  various  appliances 
employed  for  the  correction  of  irregularity  of  the  teeth  have 
already  been  described^  it  will  not  be  necessary  to  refer  to 
the  subject  again. 

Before  entering  upon  a  description  of  the  method  of  pro- 
cedure in  the  construction  of  artificial  substitutes  for  the 
natural  teeth,  and  the  manipulations  connected  therewith, 
we  shall  offer  a  few  general  remarks  on  the  subject  of  such 
substitutes — the  substances  of  which  they  are  composed — 
the  means  employed  for  their  retention  in  the  mouth,  and 
the  surgical  treatment  required  preparatory  to  their  appli- 
cation. 


CHAPTER      FIRST. 
ARTIFICIAL    TEETH. 

Contributing  as  the  teeth  do  to  the  beauty  and  agreeable 
expression  of  the  countenance — to  correct  enunciation — and 
by  the  function  of  mastication  which  they  assist  in  perform- 
ing, to  the  health  of  the  whole  organism,  it  is  not  surpris- 
ing that  their  loss  should  be  considered  a  serious  affliction, 
and  that  art  should  be  called  uj^on  to  replace  such  loss  with 
artificial  substitutes.  So  great,  indeed,  is  the  liability  of 
the  human  teeth  to  decay,  and  so  much  neglected  are  the 
means  of  their  preservation,  that  few  persons  reach  even 
adult  age  without  losing  one  or  more  of  these  invaluable 
organs.  But,  happily  for  suffering  humanity,  they  can 
now  be  replaced  with  artificial  substitutes  so  closely  resem- 
bling the  natural  organs^  as  to  be  readily  mistaken  for 
them,  even  by  the  most  critical  and  practiced  observer. 
Although  there  is  a  perfection  in  the  works,  of  nature  that 
can  never  be  equalled  by  art,  artificial  teeth  are  now,  never- 
theless, so  constructed,  as  to  subserve,  in  many  cases,  at 
least  to  a  great  extent,  the  purposes  of  the  natural  organs. 
They  are  also  worn,  when  properly  adjusted,  without  the 
slightest  discomfort — the  patient,  after  they  have  been  in 
the  mouth  a  few  days,  being  scarcely  conscious  of  their 
presence. 

The  construction  and  insertion  of  artificial  teeth,  is  an 
operation,  which,  though  acknowledged  to  be  of  great  im- 
portance, and  performed  by  every  one  having  any  preten- 
sions to  a  knowledge  of  dentistry,  is,  unfortunately,  but 
little  understood  by  the  majority  of  practitioners.  The 
mouth  is  frequently  irreparably  injured  by  their  improper 


ARTIFICIAL  TEETH.  659 

application.  A  single  artificial  tootli  badly  inserted,  may 
cause  the  destruction  of  the  two  adjacent  natural  teeth,  and 
if  the  deficiency  thus  occasioned  be  unskillfully  supplied,  it 
may  cause  the  loss  of  two  more,  and  in  this  way  all  the 
teeth  of  the  upper  jaw  are  sometimes  destroyed. 

The  utility  of  artificial  teeth  depends  upon  their  being 
properly  constructed,  and  correctly  applied.  As  much  skill 
and  judgment  are  required  for  the  practice  of  this,  as  for 
the  other  branches  of  the  art,  A  knowledge  of  the  anatomy 
and  physiology  of  the  mouth,  of  its  various  pathological 
conditions,  and  therapeutical  indications  is  as  essential  to 
the  mechanical  as  it  is  to  the  operative  dentist,  and  to  cor- 
rect information  upon  these  subjects,  should  be  superadded 
ability  to  execute  with  the  nicest  skill  and  most  perfect  ac- 
curacy, the  various  pieces  of  mechanism  required  in  dental 
prosthesis. 

There  are  difficulties  connected  with  the  insertion  of  arti- 
ficial teeth  which  none  but  an  experienced  dentist  has  any 
idea  of.  Besides,  those  of  properly  constructing  and  apply- 
ing them  in  such  a  manner,  as  that  they  may  be  easily  re- 
moved and  replaced  by  the  patient,  and  at  the  same  time, 
be  securely  fixed  in  the  mouth,  and  productive  of  no  injury 
to  the  parts  with  which  they  are  associated,  there  are  some- 
times others  equally  difficult  to  overcome.  For  example  : 
the  loss  of  a  tooth  in  one  jaw,  is  generally  followed  by  the 
gradual  protrusion  from  its  socket  of  the  one  with  which 
it  antagonized  in  the  other,  so  that  if  the  loss  of  the  form- 
er be  replaced  with  a  substitute  of  equal  size,  it  will  often 
strike  against  the  latter  at  each  occlusion  of  the  mouth,  and 
prevent  the  other  teeth  from  coming  together.  This  tenden- 
cy of  the  teeth  in  one  jaw  to  proturde,  is  always  in  proportion 
to  the  number  lost  in  the  other  ;  and  if  not  soon  counteract- 
ed by  the  replacement  of  the  latter  with  artificial  substitutes, 
it  often  gives  rise  to  an  obstacle  to  their  proper  application, 
requiring  no  little  ingenuit  y  and  tact  to  overcome. 

But,  notwithstanding  the  triumphs  of  Mechanical  Dentist- 
ry, and  the  high  state  of  excellence  to  which  it  has  arrived. 


660  ARTIFICIAL  TEETH. 

there  never  was  a  time  when  so  much  injury  was  inflicted, 
and  suffering  occasioned  by  artificial  teeth,  as  at  present, 
and  resulting^  too,  from  their  bad  construction  and  incor- 
rect application.  That  such  should  be  the  case,  when  there 
are  so  many  scientific  and  skillful  dentists  in  every  city,  and 
in  many  of  the  villages  of  the  country,  may  seem  strange, 
but  the  fact  is  nevertheless  undeniable. 

The  information  obtainable  from  works  on  mechanical 
dentistry,  was  until  recently  exceedingly  limited  ;  and  it  is 
surprising,  that  from  the  number  who  have  written  on  the 
diseases  and  loss  of  the  teeth,  this  subject  should  have  re- 
ceived so  little  attention.  Fauchard,  Bourdet,  Angermann^ 
Maury,  Delabarre,  Koecker,  Lefoulon,  Brown,  and  a  few 
others,  are  all  who  have  given  it  any  thing  more  than  a 
passing  notice  ;  and  the  works  of  but  few  of  these  writers 
contain  anything  like  explicit  directions  upon  the  subject. 
Delabarre' 8  Mechanical  Dentistry  was,  at  the  time  of  its 
publication,  a  work  of  much  merit.  The  various  methods 
adopted  at  that  period,  for  the  construction  and  application 
of  artificial  teeth,  are  accurately  and  minutely  described  in 
it — together  with  the  advantages  and  disadvantages  of  each. 
But,  however  perfect  the  work  may  then  have  been,  it  does 
not  furnish  the  information  required  upon  the  subject  at  the 
present  day.  And  still  more  deficient  in  correct  informa- 
tion are  nearly  all  the  other  French  works. 

Among  the  English  writers,  Koecker  is  almost  the  only 
one,  except  Eobinson,  a  more  recent  author,  who  has  de- 
scribed correctly  the  principles  upon  which  artificial  teeth 
should  be  applied.  His  "Essay  on  Artificial  Teeth,  Obtu- 
rators and  Palates,"  contains  much  useful  and  valuable  in- 
formation. It  does  not^  however,  contain  a  description  of 
the  manner  of  constructing  a  dental  substitute,  preparatory 
to  its  application  ;  yet,  to  one  capable  of  executing  the  va- 
rious manipulations  required  in  this  department  of  practice, 
it  is  very  serviceable.  But  as  this  ability  can  only  be  ac- 
quired by  a  regular  apprenticeship.  Dr.  K.  perhaps,  thought 
that  a  more  minute   description    was   unnecessary.     There 


ARTIFICIAL   TEETH.  661 

are  many  practitioners,  however,  wlio  are  in  other  respects 
competent,  that  have  not  enjoyed  this  advantage,  or,  at 
least,  not  in  the  mechanical  department,  and,  consequently, 
it  is  to  be  regretted,  that  he  has  not  entered  more  into  de- 
tail upon  the  subject. 

But  most  of  the  deficiencies  that  exist  in  the  last  named 
work,  were  supplied  up  to  1844,  by  Dr.  Solyman  Brown,  in 
his  series  of  papers  on  Mechanical  Dentistry,  published  in 
the  American  Journal  of  Dental  Science.  These  papers  are 
illustrated  with  numerous  cuts,  and  constitute  the  best 
treatise  upon  the  subject  that  had  appeared  up  to  the  time 
of  their  publication.  But  numerous  and  important  improve- 
ments have  subsequently  been  made  in  this  department  of 
practice.     These  will  all  be  described  in  their  j)roper  place. 

We  shall  enumerate  some  of  the  different  kinds  of  dental 
substitutes  that  have  been  employed  since  the  commence- 
ment of  the  present  century.  We  shall  also  notice  briefly, 
the  principal  methods  that  have  been  adopted  in  their  ap- 
plication, before  entering  upon  a  minute  description  of  those 
practiced  at  the  present  time.  Great  improvements  have 
been  made  in  dental  prosthesis  since  the  publication  of  the 
first  edition  of  this  work. 


CHAPTER     SECOND. 

SUBSTANCES  EMYLOYED  FOR  ARTIFICIAL  TEETH. 

There  are  certain  qualities  which  it  is  highly  important 
that  artificial  teeth  should  possess.  They  should  be  dura- 
ble in  their  nature,  and  in  their  appearance  resemble  the 
natural  organs,  with  which  they  have  often  to  be  associated. 

The  kinds  of  teeth  that  have  been  employed,  since  1830, 
are  : 

1.  Human  teeth. 

2.  Teeth  of  neat  cattle,  sheep,  &c. 

3.  Teeth  carved  from  the  ivory  of  the  elephant's  tusk, 
and  the  tooth  of  the  hippopotamus. 

4.  Porcelain  teeth. 

HUMAN    TEETH. 


As  it  regards  appearance,  and  in  a  dental  substitute  this 
is  an  important  consideration,  human  teeth  are  preferable 
to  any  other,  and  when  used  for  this  purpose^  they  should 
be  of  the  same  class  as  those,  the  loss  of  which  they  are  to 
replace.  The  crowns  only  are  employed,  and  if  well  select- 
ed, and  securely  adjusted,  the  artificial  connection  with  the 
alveolar  ridge  cannot  easily  be  detected. 

The  durability  of  these  teeth  when  thus  employed,  de- 
pends on  the  density  of  their  texture,  the  soundness  of 
their  enamel,  and  the  condition  of  the  mouth  in  which  they 
are  placed.  If  they  are  of  a  dense  texture,  with  sound  and 
perfect  enamel,  and  are  placed  in  a  healthy  mouthy  they  will 
last  from  eight  to  twelve  or  a  greater  number  of  years.  The 
difficulty,  however,  of  procuring  these  teeth,  is  generally  so 


TEETH   OF  CATTLE.  663 

great,  it  is  seldom  that  such  as  we  have  described,  can  he 
obtained,  and  even  when  they  can,  the  mouth  in  half  the 
cases  in  which  artificial  teeth  are  placed,  is  not  in  a  healthy 
condition  ;  its  secretions  are  vitiated  and  of  so  corrosive  a 
nature,  that  they  often  destroy  them  in  less  than  four  years. 
We  have  even  known  them  to  be  destroyed  by  caries  in  two, 
and  in  one  case  in  fifteen  months. 

A  human  tooth,  artificially  applied,  is  more  liable  to  de- 
cay than  one  of  equal  density  having  a  vital  connection  with 
the  general  system,  for  the  reason,  that  its  dentinal  struc- 
ture is  more  exposed  to  the  action  of  deleterious  chemical 
agents.  But  of  all  the  animal  substances  employed  for  this 
purpose,  human  teeth  are  unquestionably  the  best.  They 
are  harder  than  bone,  and  being  perfectly  protected  by 
enamel,  and  consequently  more  capable  of  resisting  the 
action  of  corrosive  agents. 

Many  object  to  having  human  teeth  placed  in  their  mouth, 
under  the  belief  that  infectious  diseases  may  be  communi- 
cated by  them.  But  there  is  no  good  foundation  for  such 
fear.  The  purifying  process  to  which  they  are  previously 
submitted,  precludes  the  possibility  of  the  communication  of 
disease.  When  the  practice  of  transplanting  teeth  was  in 
vogue,  occurrences  of  this  sort  were  not  unfrequent,  but 
since  that  has  been  discontinued,  it  has  never  hajipened. 
But,  the  prejudices  of  some  against  human  teeth  are  so 
strong,  that  it  is  impossible  to  overcome  them. 

The  difiiculty  of  procuring  them,  and  the  high  price  they 
command,  have  also  induced  many  dentists  to  profit  by  this 
popular  prejudice,  and  to  employ  other  substitutes. 

TEETH    OP    CATTLE. 

Of  the  various  kinds  of  natural  teeth  employed  for  dental 
substitutes,  those  of  neat  cattle,  are,  perhaps,  after  human 
teeth,  the  best.  By  slightly  altering  their  shape,  they  may 
be  made  to  resemble,  very  closely,  the  incisors  of  some  per- 
sons, but  a  configuration  similar  to  the  cuspids  cannot  be 


664  IVORY  AND   HIPPOPOTAMUS  TEETH. 

given  to  them ;  and  in  the  majority  of  cases  they  are  too 
white  and  glossy  to  match  very  closely  human  teeth.  The 
contrast,  therefore,  which  they  form  with  the  natural  organs 
should  constitute,  if  they  were  in  all  other  respects  accept- 
able, an  insuperable  objection  to  their  use.  This  has  been 
too  much  disregarded,  both  by  dentists  and  patients.  In- 
deed, many  of  those  who  need  artificial  teeth,  wish  to  have 
them  as  white  and  brilliant  as  possible. 

But  there  are  other  objections  to  the  use  of  these  teeth. 
In  the  first  place  they  are  only  covered  anteriorly  with 
enamel,  and,  in  the  second,  their  dentinal  structure  is  less 
dense  than  that  of  human  teeth,  and  consequently  they  are 
more  easily  acted  on  by  chemical  agents.  They  are^  there- 
fore, less  durable,  seldom  lasting  more  than  from  two  to 
four  years.  Another  objection  to  their  use  is,  they  can  only 
be  employed  in  very  few  cases,  for  their  nerve  cavities  are 
so  large,  that  by  the  time  they  are  reduced  to  the  size  of  the 
incisors,  they  become  exposed,  and  by  the  time  these  fill  up 
with  ossific  matter,  their  crowns  are  so  much  worn  away 
that  they  are  too  short,  except  in  cases  where  short  teeth  are 
required.  It  is  seldom,  therefore,  that  they  can  be  used  as 
substitutes  for  human  teeth. 

IVORY  OF  THE  TUSKS  OP  THE  ELEPHANT  AND  HIPPOPOTAMUS. 

Artificial  teeth  made  from  the  ivory  of  the  tusk  both  of 
the  elephant  and  hippopotamus  have  been  sanctioned  by 
usage  from  the  earliest  periods  of  the  existence  of  this  branch 
of  the  art ;  but  we  must  not  hence  conclude  that  it  has  been 
approved  by  experience.  On  the  contrary,  of  all  the  sub- 
stances that  have  been  used  for  this  purpose,  this  is  cer- 
tainly the  most  objectionable. 

The  ivory  of  the  elephant' s  tusk  is  decidedly  more  perme- 
able than  that  obtained  from  the  hippopotamus.  So  readily 
does  it  absorb  the  buccal  fluids  that,  in  three  or  four  hours 
after  being  placed   in  the  mouth,    it  becomes  completely 


IVORY    AND   HIPPOPOTAMUS  TEETH.  665 

penetrated  witli  tliem.  Consequently,  it  is  not  only  liable 
to  cliemical  changes,  but  also  to  become  offensive,  and  when 
several  teeth_,  formed  from  it,  are  worn,  they  aflPect  the 
breath  to  such  a  degree  as  to  render  it  exceedingly  offensive. 
But  on  account  of  its  softness,  teeth  are  easily  shaped  from 
it,  but  not  being  covered  with  enamel,  they  soon  become 
dark,  and  give  to  the  mouth  a  most  filthy  and  disgusting 
appearance.  Fortunately,  however,  in  the  United  States, 
elejjhant's  ivory  is  rarely  used  for  artificial  teeth. 

The  ivory  of  the  tusk  of  the  hippopotamus  is  much  firmer 
in  its  texture  than  that  obtained  from  the  elephant ;  and, 
bein groover ed  with  a  hard,  thick  enamel^  teeth  may  be  cut 
from  it,  which,  at  first^  very  closely  resembles  the  natural 
organs.  There  is,  however,  a  peculiar  animation  about 
human  teeth,  which  those  made  from  this  substance  do  not 
possess.  These,  moreover,  soon  change  their  color,  assum- 
ing first  a  yellow  and  then  a  dingy  bluish  hue.  They  are, 
also,  like  those  just  mentioned,  very  liable  to  decay.  We 
have  in  our  possession  a  number  of  blocks  of  this  sort, 
taken  from  the  mouths  of  different  individuals,  some  of 
which  are  nearly  half  destroyed. 

But  there  is  another  objection  to  teeth  made  of  this  sub- 
stance, which,  even  were  there  no  other,  would  be  sufficient  to 
condemn  its  use.  It  is,  that  they,  like  those  formed  from  ele- 
phant's ivory,  give  to  the  air  returned  from  the  lungs,  an 
insufferably  offensive  odor,  which  cannot  be  corrected  or  pre- 
vented. They  may  be  washed  half  a  dozen  times  a  day, 
and  taken  out  and  cleansed  again  at  night,  but  it  will  still 
be  grossly  perceptible ;  and,  although  it  may  be  worse  in 
some  mouths  than  others,  no  one  who  wears  teeth  made  of 
this  substance  is  entirely  free  from  it. 

To  one  whose  attention  has  never  been  directed  to  the 
subject,  it  would  be  astonishing  to  observe  the  effects  pro- 
duced upon  the  breath  by  wearing  two  or  three  of  these 
teeth. 


43 


666  PORCELAIN  TEETH. 


PORCELAIX    TEETH. 

The  manufacture  of  porcelain  teetli  did  not  for  a  long 
time  promise  to  be  of  mncli  advantage  to  dentistry.  But  by 
the  ingenuity  and  indefatigable  exertions  of  a  few,  they 
have,  within  the  last  twenty-five  years,  been  brought  to 
such  perfection  as  almost  to  supersede  any  other  kind  of 
artificial  teeth. 

The  French,  with  whom  the  invention  of  these  teeth 
originated,  encouraged  their  manufacture  by  favorable 
notices;  and  the  rewards  offered  by  some  of  the  learned  and 
scientific  societies  of  Paris  contributed  much  to  bring  it  to 
perfection.  They  were  still,  however,  deficient  in  so  many 
particulars,  that  they  received  the  approbation  of  very  few 
of  the  profession,  and  then  only  in  some  special  cases.  It 
is  principally  to  American  dentists  that  we  are  indebted  for 
that  Avhich  the  French  so  long  labored  in  vain  to  ac- 
complish. 

A  want  of  resemblance  to  the  other  teeth,  in  color,  trans- 
lucency,  and  animation,  was  the  great  objection  urged 
against  porcelain  teeth  ;  and,  had  not  this  been  obviated,  it 
would  have  constituted  an  insuperable  objection  to  their 
use.  Until  1833,  all  that  were  manufactured  had  a  dead 
opaque  a])pearance,  which  rendered  them  easy  of  detection, 
when  placed  alongside  of  the  natural  teeth,  and  gave  to  the 
mouth  a  sickly  aspect.  But  so  great  have  been  the  improve- 
ments in  their  manufticture,,  that  few  can  now  distinguish 
any  very  marked  difiereuce  between  them  and  the  natural 
organs. 

The  advantages  which  mineral  teeth  possess  over  every 
sort  of  animal  substance,  are  numerous.  They  can  be 
more  nicely  fitted  to  the  mouth,  and  worn  with  greater  con- 
venience. They  do  not  absorb  its  secretions,  and,  conse- 
quently, when  proper  attention  is  paid  to  their  cleanliness, 
they  do  not  contaminate  the  breath,  or  become,  in  any  way, 
offensive.     Their  color  never  changes.     They  are  not  acted 


PORCELAIN  TEETH.  667 

on  hj  the  chemical  agents  found  in  the  mouth,  and  hence 
the  name  incorruptible,  which  has  been  given  them.  The 
objections  that  have  been  urged  to  their  use,  are,  want  of 
congeniality  between  them  and  the  mouth,  they  being 
better  conductors  of  caloric  than  bone,  and,  consequently^ 
more  liable  to  become  cold  when  exposed  to  the  air,  etc. ; 
but  these  have  so  little  foundation,  that_,  when  compared 
with  the  advantages  they  confessedly  possess,  they  must  be 
regarded  as  unworthy  of  consideration. 


CHAPTER      THIRD. 

DIFFERENT  METHODS  OF  APPLYING  ARTIFICIAL  TEETH. 

The  methods  of  applying  artificial  teeth  are,  first,  on  the 
roots  of  the  natural  teeth  ;  Second,  on  plate  with  clasps  ; 
Third,  with  spiral  springs  ;  Fourth,  by  atmospheric  pres- 
isure.  The  peculiar  advantages  of  each  of  these  methods 
-we  shall  now  proceed  to  point  out,  and  the  cases  in  which 
they  are  particularly  applicable. 

ARTIFICIAL  TEETH  PLACED  m  NATURAL  ROOTS. 

This  method  of  securing  artificial  teeth,  was,  until  re- 
'cently,  on  account  of  its  simplicity,  more  extensively  prac- 
ticed than  any  other,  and,  under  favorable  circumstances, 
is,  unquestionably,  the  best  that  can  be  adopted.  If  the 
roots  on  which  they  are  placed  are  sound  and  healthy,  and 
the  back  part  of  the  jaws  supplied  with  natural  teeth,  so  as 
to  prevent  those  with  which  the  artificial  antagonize  from 
striking  them  too  directly,  they  will  subserve  the  purposes 
of  the  natural  organs  more  perfectly,  than  any  other  descrip- 
tion of  dental  substitute.  When  thus  placed,  they  rest  on 
a  firm  basis,  and  if  properly  fitted  and  secured,  their  con- 
nection with  the  natural  roots  cannot  easily  be  detected. 
But,  unfortunately,  the  incisors  and  cuspidati  of  the  upper 
jaw,  are  the  only  teeth  which  it  is  proper  to  replace  in  this 
way. 

The  insertion  of  an  artificial  tooth  on  a  diseased  root,  or 
on  a  root  having  a  diseased  socket,  is  almost  always  fol- 
lowed by  injurious  eff'ects.  The  morbid  action  already  ex- 
isting in  the  root,  or  its  socket,  is  aggravated  by  the  opera- 


METHODS   OF   APPLYING  ARTIFICIAL  TEETH.  669 

tioiij  and  often  caused  to  extend  to  the  contiguous  parts, 
and,  sometimes,  even  to  the  whole  mouth.  Nor  is  it  always 
proper  to  apply  a  tooth  immediately  after  having  prepared 
the  root.  If  any  irritation  is  produced  by  this  preparatory 
process,  the  tooth  should  not  be  inserted  until  it  has  wholly 
subsided.  The  neglect  of  this  precaution  not  unfrequently 
gives  rise  to  inflammation  of  the  alveolo-dental  periosteum 
and  alveolar  abscess. 

Although  this  method  of  securing  artificial  teeth  has  re- 
ceived the  sanction  of  the  most  eminent  dental  practitioners 
the  world  has  ever  produced,  and  is  certainly  the  best  that 
can  be  adopted  for  replacing  the  loss  of  the  six  upper  front 
teeth  ;  yet,  on  account  of  the  facility  with  which  the  opera- 
tion is  performed,  it  is  often  resorted  to  under  the  most  un- 
favorable circumstances,  and  in  consequence  of  which,  has 
been,  undeservedly,  brought  into  discredit. 

The  efforts  of  the  economy  for  the  expulsion  of  the  roots 
of  the  bicuspid  and  molar  teeth,  after  the  destruction  of 
their  lining  membrane,  are  rarely  exhibited  in  the  case  of 
roots  of  teeth  occupying  the  anterior  part  of  the  mouth. 
This  circumstance  has  led  us  to  believe,  that  the  roots  of 
these  teeth  receive  a  greater  amount  of  vitality  from  their 
investing  membrane,  than  do  the  roots  of  those  situated 
farther  back  in  the  mouth,  and  that,  though  the  amount  of 
living  principle  with  which  they  are  thus  supplied,  is  in- 
considerable, yet  it  is  sufficient  to  prevent  them  from  be- 
coming manifestly  obnoxious  to  their  sockets. 

The  admission  of  this  hypothesis  can  alone  account  for 
the  fact  to  which  we  have  just  alluded,  for  it  is  well  known 
that  a  dead  root  is  always  productive  of  injury  to  the  sur- 
rounding parts,  and  that  nature  calls  into  action  certain 
agencies  for  its  expulsion.  Therefore,  attaching  a  tooth  to 
a  completely  dead  root,  is  manifestly  improper  ;  but  the 
fangs  of  the  front  teeth  are  rarely  entirely  deprived  of 
vitality,  and  hence,  after  the  destruction  of  the  lining  mem- 
brane,  they  often    remain    ten,    fifteen,    and    sometimes,, 


670  TEETH   WITH  PLATES   AND   CLASPS. 

twenty  years,  witliout  very  obviously  affecting  the  adjacent 
parts. 

The  manner  of  preparing  a  root  and  inserting  a  tooth  on 
it  will  hereafter  be  described. 

ARTIFICIAL  TEETH  ATTACHED  TO  A  PLATE  WITH  CLASPS. 

This  method  of  applying  artificial  teeth,  is,  perhaps,  in 
favorable  cases,  with  the  exception  of  the  one  just  noticed, 
and  one  to  be  hereafter  described,  the  best  that  can  be 
adopted.  By  this  means,  the  loss  of  a  single  tooth,  or  of 
several  teeth,  in  either  or  both  jaws,  may  be  supplied.  A 
plate  may  be  so  fitted  to  an  aperture  in  the  dental  circle, 
and  secured  with  clasps  to  the  other  teeth,  as  to  afford  a 
firm  support  to  six,  eight,  ten,  or  even  twelve  artificial 
teeth. 

Teeth  applied  in  this  way,  when  properly  constructed, 
will  last  for  several  years,  and  sometimes  during  the  life  of 
the  individual.  But  it  is  necessary  to  their  durability,  that 
they  should  be  correctly  arranged,  accurately  fitted,  and 
substantially  secured  to  the  plate,  and  that  the  plate  itself 
be  properly  adapted  to  the  gums,  and  attached  to  teeth 
firmly  fixed  in  their  sockets. 

Gold  is  the  best  metal  that  can  be  employed  for  the  plate 
and  clasps.  For  the  former,  the  gold  should  be  from 
twenty  to  twenty-one  carats  fine,  and  from  eighteen  to  nine- 
teen for  the  latter.  If  gold  of  an  inferior  quality  is  used, 
it  will  be  liable  to  be  acted  on  by  the  secretions  of  the  mouth. 
Platina  would,  perhaps,  answer  the  purpose  as  well  as  gold; 
but  there  are  so  few  in  this  country  who  understand  work- 
ing it,  that  the  getting  of  it  out  into  plate,  and  such  other 
forms  as  are  required,  is  attended  with  much  difficulty  and 
inconvenience. 

The  plate  should  be  thick  enough  to  afford  the  necessary 
support  to  the  teeth ;  but  not  so  thick  as  to  be  clumsy  or 
inconvenient  from  its  weight.  The  clasps  generally  require 
to  be  about  one-third  or  one-half  thicker  than  the  plate,  and 


ARTIFICIAL   TEETH   WITH   SPIRAL   SPRINGS.  671 

sometimes  double  tlie  thickness.  The  gold  used  for  this 
purpose,  is  sometimes  prepared  in  the  form  of  half  round 
wire ;  hut,  in  the  majority  of  cases,  it  is  preferable  to  have 
it  flat,  as  such  clasps  aflbrd  a  firmer  and  more  secure  sup- 
port to  artificial  teeth  than  those  which  are  half  round; 
they  also  occasion  less  inconvenience  to  the  patient,  and  are 
productive  of  less  injury  to  the  teeth  to  which  they  are 
attached. 

Artificial  teeth,  applied  in  this  way,  may  be  worn  with 
the  greatest  comfort,  and  can  be  taken  out  and  replaced,  at 
the  pleasure  of  the  person  wearing  them  ;  and  it  is  import- 
ant that  they  should  be  very  frequently  cleansed,  to  j)revent 
the  secretions  of  the  mouth  that  get  between  the  plate  and 
gums,  and  the  clasps  and  teeth,  from  becoming  vitiated  and 
irritating  the  soft  parts,  and  corroding  the  teeth  and  taint- 
ing the  breath.  This  precaution  should,  on  no  account,  be 
neglected.  Great  care,  therefore,  should  be  taken  to  fit 
the  clasps  in  such  a  manner  as  will  admit  of  the  easy  re- 
moval and  replacement  of  the  piece,  and,  also,  that  they 
may  not  exert  any  undue  pressure  upon  the  teeth  to  which 
they  are  applied.  If  they  press  too  hard  upon  them,  they 
will  excite  inflammation  in  the  alveolo-dental  periosteum, 
and  the  gradual  destruction  of  their  sockets  will  follow  as  a 
natural  consequence. 

ARTIFICIAL  TEETH  WITH  SPIRAL  SPRINGS. 

The  only  difierence  between  the  method  last  noticed,  of 
applying  artificial  teeth,  and  the  one  now  to  be  considered, 
consists  in  the  manner  of  confining  them  in  the  mouth. 
The  former  is  applicable  in  cases  where  there  are  other  teeth 
in  the  mouth  to  which  clasps  may  be  applied — the  latter  is 
designed  for  confining  a  whole  set,  and  part  of  a  set,  where 
neither  clasps,  nor  any  other  means,  can  be  ci  iiveniently 
employed  for  their  retention  in  the  mouth. 

When  plates  with  spiral  springs  are  used,  the  teeth 
are  attached  to  them  in  the  same  manner  as  when  clasps 


672  ATMOSPHERIC   PRESSURE   METHOD. 

are  employed ;  but  instead  of  being  fastened  in  the  moutb 
to  otber  teeth,  they  are  kept  in  by  means  of  the  spiral 
sj)rings,  one  on  each  side  of  the  artificial  denture  between 
it  and  the  cheeks,  passing  from  one  piece  to  the  other. 

Spiral  springs  were  often  employed  for  confining  only  a 
lower  set  in  the  mouth,  and  sometimes  for  only  parts  of  sets. 
When  a  number  of  teeth  in  the  back  part  of  the  jaws  are 
required,  and  there  are  no  teeth  in  the  mouth  to  which 
clasps  can  be  applied,  capable  of  afi'ording  sufiicient  sup- 
port, spiral  springs  were  formerly  much  used.  Vari- 
ous other  kinds  of  springs  have  been  used,  but  none 
seem  to  answer  the  purpose  as  well  as  these.  When  they 
are  of  the  right  size,  and  attached  in  a  proper  manner,  they 
afford  a  very  sure  and  convenient  support.  They  exert  a 
constant  pressure  upon  the  artificial  pieces,  whether  the 
mouth  is  opened  or  closed.  They  do  not  interfere  in  the 
least  with  the  motions  of  the  jaw,  and,  although  they 
may  at  first  seem  awkward,  a  person  will  soon  become  so 
accustomed  to  them,  as  to  be  almost  unconscious  of  their 
presence. 

ATMOSPHERIC    PRESSURE,   OR    SUCTION    METHOD    OF    APPLYING 
ARTIFICIAL    TEETH. 

The  method  last  described,  of  confining  artificial  teeth  in 
the  mouth,  is  often  inapplicable,  inefficient  and  troublesome, 
especially  for  the  upper  jaw,  and  it  is  in  such  cases,  more 
particularly,  that  the  atmospheric  pressure,  or  suction 
method,  is  valuable.  It  was,  for  a  long  time,  thought  to  be 
applicable  only  for  an  entire  upper  set,  because  it  was  sup- 
posed that  a  plate  sufficiently  large  to  afford  the  necessary 
amount  of  surface  for  the  atmosphere  to  act  upon,  could  not 
be  furnished  by  a  piece  containing  a  smaller  number  of 
teeth.  Experience,  however,  has  proven  this  opinion  to  be 
incorrect.  A  single  tooth  may  be  mounted  upon  a  plate 
presenting  a  surface  large  enough  for  the  atmosphere  to  act 
upon  for  its  retention  in   the  mouth,  but^  when  only  a  part 


ATMOSPHERIC   PRESSURE   METHOD.  673 

of  an  upper  set  is  required,  it  is  often  necessary  to  secure 
the  piece  by  means  of  clasps.  For  a  like  reason,  it  was 
thought  that  the  narrowness  of  the  inferior  alveolar  ridge 
would  preclude  the  application  of  a  plate  to  it  upon  this 
principle,  and  in  this  opinion  the  author  participated,  but 
he  has  succeeded  so  perfectly  in  confining  lower  pieces  by 
this  means,  that  he  now  never  finds  it  necessary  to  employ 
sj)iral  springs. 

The  principle  on  which  this  plan  is  founded,  may  be 
simply  illustrated  by  taking  two  small  blocks  of  smooth  flat 
marble,  and  exhausting  the  air  from  between  them — the 
pressure  of  the  atmosphere  on  their  external  surfaces,  will 
enable  a  person  to  raise  the  under  block,  by  lifting  the  up- 
per. In  a  similar  manner,  a  gold  plate,  or  any  other  sub- 
stance, impervious  to  the  atmosphere,  and  perfectly  adapted 
to  the  gums,  may  be  made  to  adhere  to  them. 

The  firmness  of  the  adhesion  of  the  plate  or  base  to  which 
the  teeth  are  attached  to  the  gums,  depends  on  the  accuracy 
of  its  adaptation.  If  this  is  perfect,  it  will  adhere  with 
great  tenacity,  but  if  the  plate  is  badly  fitted,  or  becomes 
warped  in  soldering  on  the  teeth,  its  retention  will  often  be 
attended  with  difficulty.  It  is  also  important  that  the  teeth 
should  be  so  arranged  and  antagonized,  that  they  shall 
strike  those  in  the  other  jaw  all  the  way  round  at  the  same 
instant.  This  is  a  matter  that  should  never  be  overlooked, 
for  if  they  meet  on  one  side  before  tliey  come  together  on 
the  other,  the  part  of  the  plate  or  base  not  pressed  on,  will 
be  detached,  and  by  admitting  the  air  between  it  and  the 
gums,  will  cause  it  to  drop. 

The  application  of  artificial  teeth  on  this  principle,  has 
been  practiced  for  a  long  time  ;*  but  the  plates  formerly 
used,  were  ivory  instead  of  gold,  and  could  seldom  be  fitted 
with  sufiicient  accuracy  to  the  mouth  to  exclude  the  air  ;  so 


*  To  the  late  Mr.  James  Gardette  of  Philadelphia,  belongs  the  honor  and  credit 
of  the  discovery  of  the  practicability  of  applying  artificial  teeth  upon  this  principle. 
To  him,  also,  belongs  the  credit  of  being  the  first  to  employ  clasps  for  the  retention 
of  dental  substitutes. 


674  ATMOSPHERIC  PRESSURE  METHOD. 

that,  in  fact,  it  could  hardly  be  said  that  they  were  retained 
by  its  pressure.  Unless  fitted  in  the  most  perfect  manner, 
the  piece  is  constantly  liable  to  drop,  and  the  amount  of 
substance  necessary  to  leave  in  it,  renders  it  so  awkward 
and  clumsy,  that  a  set  of  teeth  mounted  upon  a  base  of  this 
material  can  seldom  be  worn  with  much  comfort  or  satisfac- 
tion ;  and,  besides,  ivory  absorbs  the  fluids  of  the  mouth  so 
readily,  that  after  being  worn  for  a  few  weeks  it  becomes 
exceedingly  offensive. 

The  firmness  with  which  teeth,  applied  upon  this  princi- 
ple, can  be  made  to  adhere  to  the  gums,  and  the  facility 
with  which  they  can  be  removed  and  replaced,  renders 
them,  in  many  respects,  more  desirable  than  those  fixed  in 
the  mouth  with  clasps.  But,  unless  judgment  and  proper 
skill  are  exercised  in  the  construction  of  the  teeth,  a  total 
failure  may  be  expected,  or  at  least,  they  will  never  be  worn 
with  satisfaction  and  advantage. 

There  were  few  writers,  at  the  time  of  the  publication 
of  the  first  edition  of  this  work,  who  had  even  adverted  to 
this  mode  of  applying  artificial  teeth.  Drs.  L.  S.  Parmly 
and  Koecker  had  each  bestowed  on  it  a  passing  notice. 
The  former^  in  alluding  to  the  subject,  thus  remarks : 
''Where  the  teeth  are  mostly  gone  in  both,  or  in  either  of 
the  jaws,  the  method  is,  to  form  an  artificial  set,  by  first 
taking  a  mould  of  the  risings  and  depressions  of  every  point 
along  the  surface  of  the  jaws,  and  then  making  a  correspond- 
ing artificial  socket  for  the  whole.  If  this  be  accurately 
fitted,  it  will,  in  most  cases,  retain  itself  sufficiently  firm, 
by  its  adhesion  to  the  gums,  for  every  purpose  of  speech  and 
mastication."* 

It  has  not^  until  recently,  been  thought  expedient  to  aj)- 
ply  parts  of  sets  upon  this  principle,  nor  did  we,  for  a  long 
time,  believe  the  pressure  of  the  atmosphere  and  capillary 
attraction  would  give  to  a  lower  set,  because  of  the  narrow- 
ness of  the  alveolar  ridge  of  the  inferior  maxillary,  sufficient 

*     ractical  Guide  to  the  Management  of  the  Teeth,  pp.  138-'9. 


ATMOSPHERIC  PRESSURE   METHOD.  675 

stability  to  render  it  at  all  serviceable,  but  experience  has 
fully  demonstrated  its  practicability. 

Dr.  Koecker  tells  us,  that  he  has  ''been  completely  success- 
ful in  several  instances,,  in  the  apj^lication  of  sets  for  the  up- 
per jaw  in  this  manner  ;"  and  he  says,  they  "should  be  made 
either  with  a  gold  plate  mounted  with  natural  or  artificial 
teeth^  or  of  one  piece  of  hippopotamus'  tooth."*  Having 
already  stated  the  objections  that  exist  to  the  use  of  this 
substance,  we  cannot  join  with  Dr.  K.  in  its  recommenda- 
tion. At  the  time  when  we  first  substituted  the  gold  plate 
for  it,  we  had  not  seen  his  late  work  on  artificial  teeth,  and, 
consequently,  was  not  aware  that  the  use  of  metal  for  a 
base  had  ever  before  been  recommended. 

Upon  the  ordinary  method  of  applying  artificial  teeth  on 
this  princij)le,  considerable  improvement  has  been  made 
since  1845.  By  constructing  the  plate  with  an  air  chamber 
or  cavity,  so  that  when  the  air  is  exhausted  from  between  it 
and  the  parts  against  which  it  is  placed,  a  vacuum  is  form- 
ed, and  it  adheres  with  greater  tenacity  to  the  gums  than 
a  base  fitted  simply  to  them. 

Other  methods  have  been  resorted  to  for  the  retention  of 
artificial  teeth,  but  as  they  have  long  since  been  abandoned, 
a  description  of  them  is  rendered  unnecessary. 

*  Koecker  on  Artificial  Teeth,  p.  92. 


CHAP  TER    FOURTH. 

SURGICAL   TREATMENT  OF  THE  MOUTH  PREPARATORY 
TO  THE  APPLICATION  OF  ARTIFICIAL  TEETH. 

The  condition  of  the  mouth  is  not  sufficiently  regarded  in 
the  ajDplication  of  artificial  teeth,  and  to  the  neglect  of  this, 
the  evil  effects  that  often  result  from  their  use,  are  fre- 
quently attributable.  No  artificial  appliance,  no  matter 
how  correct  it  may  be  in  its  construction  and  in  the  mode  of 
its  application,  can  be  worn  with  impunity  in  a  diseased 
mouth.  Of  this  fact,  every  day's  experience  furnishes  the 
most  abundant  proof.  Yet  there  are  men  in  the  profession, 
so  utterly  regardless  of  their  own  reputation  and  the  conse- 
quences to  their  patients,  as  to  wholly  disregard  the  condi- 
tion of  the  mouth,  and  are  in  the  constant  habit  of  applying 
artificial  teeth  upon  diseased  roots  and  gums,  before  the 
curative  process,  after  having  extracted  the  natural  teeth, 
is  half  completed. 

The  dentist,  it  is  true,  may  not  always  be  to  blame  for 
omitting  to  employ  the  means  necessary  for  the  restoration 
of  the  mouth  to  health.  The  fault,  oftentimes,  is  with  the 
patient.  There  are  many,  who,  after  being  fully  informed 
of  the  evil  effects  which  must  of  necessity  result  from  such 
injudicious  practice,  still  insist  on  its  adoption.  But  the 
dentist,  in  such  cases,  does  wrong  to  yield  his  better  in- 
formed judgment  to  the  caprice  or  timidity  of  his  patient, 
knowing,  as  he  should^  the  lasting,  pernicious  consequences 
that  must  result  from  doing  it.  If  he  is  not  permitted  to 
carry  out  such  plan  of  treatment  as  may  be  necessary  to  put 
the  mouth  of  his  patient  in  a  healthy  condition,  previously 


SURGICAL   TREATMENT   OF   THE   MOUTH.  677 

to  the  application  of  artificial  teethj  he  should  refuse  to 
render  his  services. 

Dr.  Koecker,  in  treating  upon  this  suhject,  says,  ''There 
is,  perhaps,  not  one  case  in  a  hundred,  requiring  artificial 
teeth,  in  which  the  other  teeth  are  not  more  or  less  diseased 
and  the  gums  and  alveoli,  also,  either  primarily  or  second- 
arily afiected.  The  mechanical  and  chemical  bearing  of  the 
artificial  teeth  upon  such  diseased  structures,  naturally  he- 
comes  an  additional  powerful  aggravating  cause  of  disease, 
already  in  a  sufficient  state  of  excitement,  even  if  the  teeth 
are  mechanically  well  contrived  and  inserted  ;  if,  however, 
they  are  not  well  constructed,  and  are  inserted  with  undue 
means  or  force,  or  held  by  too  great  or  undue  pressure,  or 
by  ligatures  or  other  pernicious  means  for  their  attachment, 
the  morbid  effects  are  still  more  aggravated,  and  a  general 
state  of  inflammation  in  the  gums  and  sockets,  and  particu- 
larly in  the  periosteum,  very  rapidly  follows.  The  patient, 
moreover^  finds  it  impossible  to  preserve  the  cleanliness  of 
his  mouth  ;  and  his  natural  teeth,  as  well  as  the  artificial 
apparatus,  in  combination  with  the  diseases  of  the  struc- 
tures, becomes  a  source  of  pain  and  trouble ;  and  the  whole 
mouth  is  rendered  highly  offensive  and  disgusting  to  the 
patient  himself,  as  well  as  to  others."* 

The  first  thing,  then,  claiming  the  attention  of  the  den- 
tist, when  applied  to  for  artificial  teeth,  is  to  ascertain  the 
condition  of  the  gums  and  of  such  teeth  as  may  be  remain- 
ing in  the  mouth.  If  either  or  both  are  diseased,  he  should 
at  once  institute  such  treatment  as  the  circumstances  of  the 
case  may  indicate,  but  as  this  has  been  described  in  a  pre- 
ceding place,  it  is  only  necessary  now  to  refer  the  reader  for 
directions  upon  the  subject,  to  what  is  there  said. 

When  artificial  teeth  are  to  be  secured  in  the  mouth  in 
any  other  way  than  on  roots,  sufficient  time  should  elapse 
before  their  insertion,  for  ^he  completion  of  all  those  changes 
that  follow  the  treatment  which  is  usually  necessary  in  such 

♦  Vide  Koecker's  Essay  on  Artificial  Teeth,  pp.  27,  28. 


678        SURGICAL  TREATMENT  OF  THE  MOUTH. 

cases  ;  otherwise^  instead  of  being  worn  with,  comfort,  fhey 
will  be  a  source  of  constant  irritation.  If  tliey  are  applied 
too  soon,  tliey  will  lose  their  adaptation  to  the  gums.  We 
have  now  in  our  possession  a  number  of  parts  of  sets,  which, 
from  having  been  prematurely  applied,  and  the  changes  in 
the  shape  of  the  parts  on  which  they  rested^  that  followed 
their  insertion,  pressed  so  unequally  on  the  gums,  that 
their  removal  became  absolutely  necessary  for  the  relief  of 
the  irritation  and  pain  they  occasioned.  The  persons  from 
whose  mouths  they  were  taken  assured  us,  that  at  the  time 
of  their  application  they  fitted  very  accurately,  and  were 
worn  for  a  short  time  with  comfort. 

It  is  often  necessary  to  wait  from  eight  to  fifteen  months 
after  the  removal  of  the  natural  teeth^  for  the  completion  of 
the  changes  which  take  place  in  the  alveolar  ridge  after 
such  operation .  In  the  meantime,  if  necessary,  th.e  patient 
may  be  supplied  with  a  temporary  substitute. 


CHAPTER      FIFTH. 

MAMER  OF  PREPARING  A  NATURAL  ROOT  AND  SECURING 
AN  ARTIFICIAL  CROWN  TO  IT. 

Previously  to  the  preparation  of  a  natural  root  for  the 
reception  of  an  artificial  tooth,  the  remaining  teeth  and 
gums,  if  diseased,  should  be  restored  to  health.  This  done, 
such  portion  of  the  crown,  as  may  not  have  been  previously 
destroyed  by  caries,  should  be  removed  with  an  oval  or  half- 
round  file. 

The  usual  method  of  performing  this  part  of  the  opera- 
tion, consists  in  cutting  the  tooth  about  three-fourths  off  with 
a  file,  and  then  to  remove  it  with  a  pair  of  excising  forceps. 
But  the  forceps  should  not  be  applied  until  the  tooth  has 
been  cut  with  a  file  on  every  side,  nearly  to  the  pulp  cavity, 
and  even  then  great  care  is  necessary  to  prevent  jarring,  or 
otherwise  injuring  the  root.  When  too  large  a  portion  of 
the  crown  is  dipt  off  suddenly  with  excising  forceps,  the 
concussion  is  often  so  great  as  to  excite  inflammation  in  the 
socket  of  the  tooth,  and  sometimes  to  shatter  the  root. 

When  excising  forceps  are  used,  they  should  be  strong, 
so  as  not  to  spring  under  the  pressure  of  the  hand,  with 
cutting  edges  about  an  eighth  of  an  inch  wide. 

After  the  removal  of  the  remaining  portion  of  the  crown, 
the  nerve,  if  still  alive,  should  be  immediately  destroyed, 
by  introducing  a  silver  or  iron  wire,  or  some  other  small 
sharp-pointed  instrument,  up  to  the  extremity  of  the  root, 
giving  it,  at  the  same  time,  a  quick  rotary  motion.  It  is 
important  that  the  instrument  used  for  this  purj)Ose,  if  it 
be  of  metal,  should  be  soft  and  yielding,  otherwise,  any 
sudden  motion  of  the  head  of  the  patient  might  break  it 
in  the  tooth. 


680  MANNER    OF  SECURING   A   PIVOT   TOOTH. 

Some  recommend  destroying  the  nerve  by  the  introduc- 
tion of  a  hot  wire  into  the  canal  of  the  root,  but  as  this  is 
very  liable  to  produce  irritation  in  the  surrounding  tissues, 
the  other  method  is  preferable. 

The  nerve  having  been  destroyed,  the  remainder  of  the 
operation  will  be  painless.  The  root  may  now  be  filed  ofi" 
a  little  above  the  free  edge  of  the  gum ,  with  an  oval  or  half 
round  file.*  The  exposed  extremity  of  the  root,  after  hav- 
ing been  thus  filed,  will  present  a  slightly  arched  appear- 
ance, corresponding  with  the  festooned  shape  of  the  ante- 
terior  margin  of  the  gum. 

After  having  completed  this  part  of  the  operation,  the 
natural  canal  in  the  root  should  be  slightly  enlarged  with 
a  burr-drill,  or  a  broach  prepared  for  the  purpose.  The 
canal  thus  formed  in  the  root  for  the  pivot  should  never  ex- 
ceed the  sixteenth  part  of  an  inch  or  a  line  in  diameter,  and 
a  quarter  or  three-eighths  of  an  inch  in  length. 

If  from  any  jjeculiar  constitutional  susceptibility  there  is 
reason  to  apprehend  inflammation  of  the  alveolo-dental 
membrane,  the  insertion  of  the  tooth  may  be  delayed  a  few 
days  for  the  subsidance  of  any  irritation  which  may  have 
been  occasioned  by  the  preiDaration  of  the  root,  but  it  rarely 
happens  that  the  operation  is  followed  by  any  unpleasant 
efi'ects,  unless  this  has  previously  lost  its  vitality  by  the 
spontaneous  disorganization  of  the  nervous  pulp.  In  this 
case,  an  outlet  may  be  made  by  cutting  a  groove  on  the  side 
of  the  pivot,  or  in  some  other  way,  for  the  escape  of  any 
matter  which  may  form  at  the  apex  of  the  root.  Dr.  May- 
nard  believes  that  the  irritation  in  most  cases,  arises  from 
an  accumulation  of  acrid  matter  in  the  upper  part  of  the 
root,  and  that  by  filling  the  natural  canal  above  the  termi- 
nus of  the  pivot,  up  to  the  extremity,  it  may  generally  be 
prevented.     This  should  always  be  done. 

After  having  prepared  the  root,  an  artificial  crown  of  the 
right   shape,  color  and  size,  is  accurately  fitted  to  it.     It 

*  The  file  employed  for  this  purpose  should  be  of  the  best  quality,  and  double  or 
cross-cut  and  rather  coarse  than  otherwise. 


MANNER   OF   SECURING   A   PIVOT   TOOTH. 


681 


should  toiicli  every  part  of  tlie  filed  extremity  of  the  root, 
and  made  to  rest  firmly  upon  it,  and  at  the  same  time  be  in 
an  exact  line  with  the  circle  of  the  other  teeth.  If  the  tooth 
is  only  fitted  anteriorly,  an  opening  will  be  left  between  it 
and  the  root  posteriorly,  which  will  serve  as  a  lodgement 
for  foreign  matter,  and  the  substitute  will  also  have  a  less 
secure  support.  Nor  should  the  new  tooth  press  against  the 
adjoining  teeth,  or  strike  its  antagonist  before  the  other 
teeth  come  tosrether. 

The  canal  in  the  root,  and  that  in  the  artificial  crown, 
should  be  directly  opposite  to  each  other.  When  the  crown 
of  a  natural  tooth  is  used,  the  proper  place  for  the  pivot  is 
indicated  by  the  pulp  cavity,  but  in  porcelain  teeth  the  hole 
is  not  always  in  the  centre. 

When  the  latter  are  used,  one  should  be  selected  of  the 
proper  length,  width  and  thickness.  It  should  be  as  nearly 
as  possible  the  shade  of  the  adjoining  teeth,  and  it  would 
be  preferable  to  have  it  even  a  shade  darker  than  any  lighter, 
as  in  the  former  case  the  contrast  would  be  less  perceptible 
than  in  the  latter.  If  necessary  to  make  any  change  in  the 
shape,  it  may  be  readily  effected  Fio.  153. 

on  a  small  grindstone,  or  an 
emery  or  corundum  wheel  or 
slab.  A  great  number  of  grind- 
ing apparatuses  have  been  in- 
vented for  this  purpose.  Some 
are  very  simple  in  their  construc- 
tion, consisting  of  a  single  wheel 
turned  with  a  crank,  others  are 
more  complex  in  their  arrange- 
ment :  but  the  object  may  easily 
and  readily  be  accomplished 
with  any  now  in  use.  Those  of 
the  simpler  construction  are  kept 

by  most  instrument  makers,  from  whom  they  can  be  procured. 
The  one  represented  in  Fig.  153,  which  may  be  readily  se- 
cured to  a  table,  will,  perhaps,  answer  the  purpose  as  well 
44 


682  MAXXER   OF   SECURING   A   PR'OT  TOOTH. 

as  any  now  in  use.  It  occupies  but  little  space,  and  altliongli 
moved  with  a  crank_,  with  the  hand,  will,  if  the  wheel  is 
good,  cut  away  a  tooth  very  rapidly.  But  for  fitting  por- 
celain teeth  to  plates,  a  wheel  moved  by  a  foot-lathe,  in  the 
manner  to  be  hereafter  described,  will  be  found  preferable 
to  the  one  represented  here ;  or  a  small  hand  lathe,  recently 
invented  by  Mr.  Pratt,  dentist,  of  Baltimore,,  may  be  used. 
In  the  absence  of  a  grinding  wheel,  a  corundum  slab  may 
be  employed. 

When  the  crown  of  a  natural  tooth  is  used,  any  change 
which  it  may  be  necessary  to  make  in  its  shape,  is  made 
with  a  file.* 

The  artificial  crown  may  be  secured  to  the  root  by  means  of 
a  pivot  made  of  wood  or  metal ;  when  the  latter  is  employed, 
gold  or  platina  is  preferable  to  any  other,  inasmuch  as  silver 
or  any  baser  metal  is  liable  to  be  oxydized  by  the  fluids  of 
the  mouth.  If  wood  is  used,  it  should  be  of  the  best 
quality  of  well  seasoned  white  hickory,  as  this  possesses 
greater  strength  and  elasticity  than  any  other  that  can  be 
procured  in  this  country.  After  being  reduced  to  near  the 
size  of  the  orifice  of  the  cavity  in  the  artificial  tooth,  it 
should  be  forced  thiough  a  smooth  hole,  of  the  size  of  that, 
in  a  piece  of  ivory,  bone^  steel,  or  some  other  hard  sub- 
stance, for  the  purpose  of  compressing  its  fibres  as  closely 
together  as  possible.  Thus  prepared,  one  end  is  forced 
into  the  cavity  in  the  artificial  crown,  and  the  project- 
ing part  cut  oft'  about  a  quarter  or  three-eigliths  of  an 
inch  from  the  tooth,  and  this,  after  being  reduced  to  the 
size  of  the  orifice  in  the  root,  is  inserted  in  it;  pressure  is 
now  applied  with  tlie  thumb  and  finger  of  the  operator,  to 
the  tooth,  and  the  pivot  forced  up  into  the  canal  of  the  root 
until  the  two  come  together.     The  part  of  the  pivot  going 


*  To  obviate  the  difficulty  sometimes  experienced  in  making  a  perfect  joint  be- 
tween the  root  and  crown,  Dr.  E.  Townsend,  of  Philadelphia,  has  recently  in- 
vented two  very  excellent  instruments,  consisting;  of  an  oval  and  hollow  file — the 
former  fitting  exactly  into  the  latter.  With  the  first  he  files  the  root,  and  with  the 
other,  the  base  or  part  of  the  crown  to  be  fitted  to  it. 


MANNER   OF   SECURING   A   PIVOT  TOOTH. 


G83 


into  the  root,  should  never  be  so  large  as  to  require  any 
other  pressure  than  that  which  can  be  applied  with  the 
thumb  and  fore-finger,  as  the  swelling  of  the  wood  will 
soon  render  it  sufiiciently  tight  to  hold  it  firmly  in  its  place. 
The  i")ractice  of  driving  a  pivot  up  with  a  hammer^  as  is 
often  done,  is  a  bad  one.  It  is  apt  to  cause  inflammation 
and  suppuration  of  the  soft  tissues  about  the  apex  of  the 
root. 

A  porcelain  tooth  with  a  wood  pivot,  previously   ^^^-  ^^^' 
to  insertion,  presents  the  appearance  represented 
in  Fig.  154. 

It  sometimes  becomes  necessary  to  remove  the 
artificial  crown,  and  in  doing  this^  the  j)ivot  often  remains 
in  the  root.  For  the  removal  of  this,  the  forceps  represented 
in  Fig.  155,  invented  by  Dr.  W.  H.  Elliott,  will  be  found 
very  useful.     With  this  instrument  the  pivot  may  be  re- 

FiG.  155. 


moved  from  the  root  without  jarring  it  in  the  least,  or  ex- 
erting any  extractive  force  upon  it.  The  manner  of  apply- 
ing and  using  the  instrument  will  be  readily  understood  by 
examining  the  above  cut. 


684  MANNER   OF    SECURING   A   PIVOT    TOOTH. 

Fig.  156,  When  a  metallic  pivot  is  used,  tlie  end  going 
into  the  artificial  crown  may  be  fastened  in 
either  of  the  following  ways,  namely,  first,  by 
cntting  a  screw  on  it,  either  with  a  file,  or  pass- 
ing it  through  a  screw  plate ;  the  cavity  in  the  crown  should 
next  be  filled  with  a  wooden  tube,  and  the  pivot  then  screwed 
into  it.  Second,  by  filling  the  cavity  in  the  crown  with 
pulverized  borax,  moistened  with  water,  inserting  the  end 
of  the  pivot  into  it,  which  should  be  large  enougli  to  fill 
the  cavity,  placing  several  small  pieces  of  solder  around  it, 
and  applying  heat  to  the  tooth  by  means  of  a  blow-pipe 
and  lamp  until  it  fuses  and  flows  down  around  it  into  the 
tooth.  The  solder,  by  adapting  itself,  when  in  a  state  of 
fusion_,  to  the  rough  walls  of  the  cavity  in  the  crown  of  the 
tooth,  will  prevent  the  pivot  from  loosening  or  coming  out. 
The  projecting  part  of  the  pivot  should  be  about  half  an 
inch  in  length,  square  and  pointed.  The  cavity  in  the  root, 
which  requires  to  be  deeper  for  a  metallic  than  for  a  wood 
pivot,  should  be  filled  with  wood,  having  a  small  hole 
through  the  centre.  Into  this,  the  end  of  the  pivot  is  intro- 
duced and  forced  up,  until  the  tooth  and  root  come  firmly 
together.  The  appearance  of  a  porcelain  tooth,  prepared 
with  a  metallic  pivot,  for  insertion  in  the  manner  as  just 
described,  is  shown  in  Fig.  156. 

Fig.  157.  But  when  a  metallic  pivot  is  user),  a  plate- 

tooth  is  preferable  to  one  made  expressly  for 
a  pivot.  The  manner  of  attaching  a  pivot 
to  the  former,  is  as  follows :  the  root  is 
first  prepared  ;  after  which,  an  impression 
is  taken  in  wax  ;  from  this,  a  plaster  cast  is 
made,  and  from  the  latter,  metallic  casts.  This  done,  a 
piece  of  gold  plate,  large  enough  to  cover  the  root,  should 
be  swaged  up  between  the  metallic  casts,  a  plate  tooth  of 
the  proper  size,  sliape  and  color,  is  then  fitted  to  the  root, 
backed  with  gold,  and  soldered  to  the  plate  previously  fitted 
to  the  root,  and  to  the  upper  or  convex  surface  of  this  last, 


MANNER    OF   SECURING   A   PIVOT  TOOTH.  685 

and  immediately  beneath  the  canal  in  the  root,  a  gold  pivot 
is  attached.  But  for  the  manner  of  conducting  these  vari- 
ous processes,  the  reader  is  referred  to  a  succeeding  chap- 
ter. A  front  and  side  view  of  a  tooth  thus  prepared  is 
shown  in  Fig.  157. 

A  pivot,  consisting  of  gold  encased  in  a  thin  layer  of 
wood,  constitutes  about  as  secure  a  means  of  attachment  as 
can  bo  employed.  It  is  prepared  in  the  following  manner  : 
the  gold  is  first  made  into  wire  of  the  proper  size,  and 
passed  through  a  screw-plate.  A  hole  is  then  drilled 
lengthwise  into  a  piece  of  well  seasoned  hickory,  as  far  as 
required  for  the  length  of  the  pivot.  Into  this  the  wire  is 
screwed,  and  then  cut  off  close  to  the  wood,  wliich  is  reduced 
with  a  file  or  knife,  to  the  size  of  the  orifice  in  the  artificial 
crown,  into  which  it  is  firmly  forced.  The  projecting  part 
of  the  wood  is  trimmed  down  to  the  size  of  the  tube  in  the 
root,  to  the  termination  of  the  wii-e,  and  cut  off,  when  the 
tooth  is  ready  for  insertion. 

The  wood  prevents  the  gold  from  enlarging  the  cavity  of 
the  root,  or  that  of  the  artificial  tooth  ;  and  at  the  same 
time,  by  the  swelling  of  this  encasement,  the  pivot  is  firmly 
retained  in  both. 

There  is  some  diversity  of  opinion  with  regard  to  the 
^best  kind  of  pivots.  Some  prefer  wood,  others  metal.  Dr. 
Fitch,  on  this  subject,  observes:  "The  metallic  pivots  are 
far  ])etter  than  any  other  ;  and  their  only  objection  is,  that 
they  are  apt  to  wear  the  tooth  that  is  placed  upon  them, 
and  the  stump  in  which  they  are  inserted  ;  and  so  much  so 
do  they  have  this  eflFect,  that  we  are  induced  to  use  pivots  of 
wood.  This  last  has  the  advantage  if  perfectly  seasoned,  of 
swelling  in  the  stump,  by  the  moisture  which  they  absorb  ; 
and,  in  this  way,  become  very  firm.  The  advantages  and 
disadvantages  of  the  two  kinds,  are,  perhaps,  nearly  bal- 
anced." 

To  the  use  of  wood.  Dr.  Koecker  is  decidedly  opposed. 
''The  pivots,"  says  he,  ''should  be  made  only  of  fine  gold 
or  platina  ;  every  other  metal,  such  as  brass,  copper,  silver, 


686  MANNER    OF   SECURING   A   PIVOT   TOOTH. 

and  even  inferior  gold^  are  highly  ohjectionahle,  heing  more 
or  less  liable  to  corrode,  and  thus  become  injurious  to  the 
other  teeth  and  the  general  health.  There  is,  however,  a 
practice  which  is  still  more  improper,  namely,  the  use  of 
pivots  made  of  wood  ;  these  pivots,  after  insertion,  consider- 
ably expand,  from  the  moisture  of  the  mouth,  and  conse- 
quently remain  perfectly  firm  in  the  roots  for  several  years, 
which  deceive  not  only  the  patient,  but  the  dentist  also, 
and  induces  them  to  consider  the  case  very  successful,  until 
they  at  last  find  that  the  root  is  either  split  by  the  swelling 
of  the  pivot,  or  nearly  destroyed  by  the  rapid  decay  of  the 
wood  in  the  cavity,  which,  by  its  chemical  and  mechanical 
irritation,  is  very  apt  to  produce  very  serious  inflammation, 
and  other  affections  of  the  gums  and  sockets  ;  and  not  the 
least  objection,  the  disagreeable  breath,  which  must  be  an 
unavoidable  concomitant  of  this  practice." 

Again  on  the  insertion  of  pivoted  teeth,  Dr.  K.  in  another 
place  adds  :  "I  have  made  it  an  universal  rule  to  insert  the 
tooth  in  such  a  manner,  that  the  jDatient  should  be  capable, 
after  receiving  the  necessary  instructions,  to  remove  it,  and 
replace  it,  at  pleasure  ;  for  this  purpose,  I  have  found  it 
best,  and  most  effectual,  to  wind  a  little  cotton  round  the 
pivot,  which  should  be  filed  somewhat  rough,  previous  to 
its  insertion  into  the  fang." 

The  description  here  given  of  the  effects  supposed  to  be 
produced  by  a  wood  pivot,  is,  perhaps,  somewhat  exaggera- 
ted. If  made  properl}'  of  good  wood,  it  is  no  more  liable  to 
produce  irritation,  and  to  affect  the  breath,  than  gold 
■wrapped  with  cotton,  or  one  made  of  any  other  metal.  The 
fact  tliat  wood  pivots  remain  firmly  in  the  roots  for  several 
years,  ought  rather  to  be  considered  as  a  recommendation^ 
than  an  objection  ;  and  with  us,  we  must  confess,  it  would 
go  far  towards  determining  our  preference  in  their  favor  : 
for  the  frequent  rem.ival  and  replacement  of  a  pivoted  tooth, 
greatly  tends  to  hasten  the  destruction  of  the  root,  and  to 
irritate  surrounding  parts. 


MANNER   OF   SECURING   A   PIVOT   TOOTH.  687 

As   a   general   rule,   not    more  Fia.  i58. 

than  two  roots  should  be  prepared 
at  one  sitting,  though  sometimes 
four  or  even  six  may  be  prepared 
without  incurring  any  risk.  Fig. 
158  represents  the  roots  of  the  four  upper  incisors,  prepared 
for  the  reception  of  artificial  teeth_,  and  the  teeth  armed 
with  wood  pivots,  ready  to  be  inserted. 

When  a  tooth  is  attached  by  any  of  the  ordinary  modes 
of  pivoting,  the  walls  of  the  canal  in  the  root,  are,  of  ne- 
cessity, exposed  to  the  action  of  the  fluids  of  the  mouth, 
andj  consequently,  are  gradually  softened  and  broken  down, 
so  that  in  the  course  of  a  few  years  a  larger  pivot  will  be 
required,  and  this,  too,  after  awhile,  will  have  to  be  re- 
placed with  one  still  larger,  until,  finally,  the  root  is  de- 
stroyed. This  destructive  process  proceeds  more  rapidly  in 
some  cases  than  in  others,  according  as  the  root  is  hard  or 
soft,  and  as  the  secretions  of  the  mouth  are  in  a  healthy  or 
vitiated  condition. 

But  this  may  be  prevented  by  introducing  a  hollow  gold 
screw  for  the  reception  of  the  pivot.  This  protects  the  walls 
of  the  canal  against  the  action  of  corrosive  agents,  and 
a  root  thus  prepared,  will  support  an  artificial  crown  more 
than  twice  as  long  as  when  prepared  in  the  ordinary  way. 
The  operation,  however,  is  more  tedious  and  expensive,  but 
it  is  fir  more  valuable. 

For  the  preparation  of  a  tooth  in  this  manner,  the  follow- 
ing is  the  method  of  procedure.  First,  the  crown  of  the 
natural  tooth  is  removed,  the  nerve,  if  alive,  destroyed,  and 
the  canal  in  the  root  enlarged  in  the  manner  as  before 
directed.  Second,  a  screw  tap,  slightly  larger  than  the 
canal  in  the  root,  is  then  introduced  for  the  purpose  of  cut- 
ting a  screw  on  its  inner  walls.  Third^,  a  screw  is  then  cut 
on  a  piece  of  hollow  gold  wire^  of  the  size  of  the  screw  tap, 
by  passing  it  through  a  screw  plate,  but  during  this  process 
the  hollow  in  the  wire  is  filled  with  another  wire  to  prevent 
injury.     This  done,  it  may  be  screwed  into  the  root  about  a 


688  MANNER   OF   SECURING   A   PIVOT   TOOTH. 

quarter  of  an  inch,  the  wire  on  the  inside  of  it  is  then  with- 
drawn, and  the  lower  or  protruding  extremity  filed  off  even 
with  the  root,  with  a  very  fine  file.  Fourth,  an  artificial 
tooth  is  now  selected,  of  the  right  size,  shape  and  color, 
and  fitted  to  the  root,  after  which  a  gold  pivot  is  fixed  in  it 
in  the  manner  as  before  directed,  of  the  exact  size  of  the 
hollow  in  the  screw,  and  to  the  length  of  which  it  should 
also  correspond.  Having  proceeded  thus  far,  the  operation 
is  completed  by  applying  the  tooth  to  the  root.  The  pivot 
being  of  the  size  of  the  hollow  in  the  cylindrical  screw,  but 
little  pressure  is  required  to  force  the  one  into  the  other. 

The  stability  of  a  tooth  secured  in  this  manner,  is  as  great 
if  the  pivot  be  of  the  proper  size,  as  one  inserted  by  any  of 
the  other  methods,  and  it  may  be  removed,  cleansed,  and 
replaced  at  the  pleasure  of  the  patient.  When  the  walls  of 
the  canal  are  so  much  enlarged  by  decay  as  to  have  formed 
a  large  conical  shaped  cavity  in  the  lower  extremity  of  the 
root,  the  upper  end  of  the  hollow  or  cylindrical  screw  will 
only  take  effect.  In  this  case  the  space  between  the  lower 
extremity  and  the  walls  of  the  root,  are  thoroughly  filled 
with  gold  before  the  wire  on  the  inside  is  withdrawn  ;  after 
which  the  tube  and  extruding  portions  of  the  gold  are  filed 
off  even  with  the  root,  and  polished  before  the  artificial  tooth 
is  applied. 

The  hollow  wire  is  made  by  wrapping  a  piece  of  thin  gold 
plate  round  a  wire  of  the  size  of  that  to  be  used  for  the 
pivots.  It  is  then  drawn  through  a  hole  in  a  wire-plate. 
The  inner  wire  is  then  removed,  and  the  seam  in  the  other 
soldered.  But  hollow  wire  may  be  procured  of  the  proper 
size  at  much  less  expense  than  it  can  be  made  by  a  dentist, 
and  with  this  every  practitioner  should  be  supplied. 

It  sometimes  happens  that  the  natural  root,  instead  of 
occupying  a  vertical  position  in  the  jaw,  passes  up  obliquely, 
so  that  if  the  pivot  connecting  the  artificial  tooth  to  it  be 
straight,  the  latter  will  either  overlap  one  of  the  adjoining 
teeth  or  project  forwards  or  point  towards  the  interior  of  the 


MANNER   OF   SECURING   A   PIVOT  TOOTH.  689 

mouth.  To  obviate  this,  an  angle  should  be  given  to  the 
pivot,  immediately  at  the  point  of  junction  between  the 
tooth  and  root.  A  little  practice  will  enable  the  operator 
readily  to  overcome  a  difficulty  of  this  description. 

Again,  it  sometimes  happens  that  cases  are  met  with 
presenting  a  still  more  formidable  difficulty  ;  as  for  example, 
when  the  root  is  situated  behind  the  circle  of  the  other  teeth, 
and  to  obviate  which,  a  different  kind  of  tooth,  and  an  en- 
tirely different  course  of  procedure  is  necessary.  In  a  case 
of  this  sort,  after  having  prepared  the  root,  an  impression 
of  the  parts  are  taken  in  wax,  from  which  a  plaster  model 
is  obtained,  and  from  this  two  metallic  casts.  Be-  p^^^  159^ 
tween  these  last  a  gold  plate  extending  just  far 
enough  back  to  cover  the  root  and  forward  to  form 
a  line  with  the  outer  circle  of  the  teeth.  To  the 
superior  part  of  the  plate  covering  the  root,  and  di- 
rectly beneath  the  cavity  in  it,  a  gold  j^ivot,  about  fig.  I60. 
three-eighths  of  an  inch  long,  is  soldered,  and  to  the 
anterior  part  of  it  a  plate  tooth  of  the  right  size, 
shape,  and  shade,  is  attached.  A  piece  of  hollow  IPII 
wood  or  a  hollow  gold  screw,  as  before  described, 
is  now  introduced  into  the  root,  and  into  this  the  gold  pivot 
is  forced. 

A  side  view  of  a  porcelain  tooth,  mounted  on  a  plate  with 
a  pivot,  for  insertion  in  the  manner  here  described,  is  repre- 
sented in  Fig.  159,  and  in  Fig.  160  a  back  view  is  shown. 
It  is  a  substitute,  as  will  be  perceived  by  the  engraving,  far 
the  right  su]Derior  central  incisor. 

A  description  of  the  manner  of  obtaining  an  impression 
with  wax,  plaster,  &c.,  of  procuring  a  j^laster  model,  me- 
tallic casts_,  of  fitting  a  plate  and  attaching  teeth  to  it,  and 
finishing  a  piece,  will  be  hereafter  described.  It  is  not 
necessary,  therefore,  to  dwell  upon  this  part  of  the  subject 
here. 

But  before  we  proceed  to  do  this,  it  will  be  proper  to  offer 
a  few  remarks  on  the  manner  of  refiuing  and  alloying  gold, 
making  it  into  plate,  springs  and  solder. 


CHAPTER     SIXTH. 

MAXXER  OF  REFLMXG  AND  ALLOYING  GOLD-MAKING 
PLATE,  CLASPS,  SPRINGS,  ETC.,  FOR  ARTIFICIAL  TEETH, 
AND  SOLDER  SUITABLE  FOR  UNITING  THE  DIFFERENT 
PARTS  OF  A  PIECE  OF  DENTAL  MECHANISM. 

Gold,  as  lias  already  been  stated,  is  the  best  metal  which 
can  be  employed  in  connection  with  artificial  teeth,  mounted 
in  the  ordinary  way,  because  it  is  the  only  one  capable  of 
resisting  the  action  of  the  secretions  of  the  mouth,  except 
platina,  which,  as  regards  indestructibility,  answers  equally 
well^  but  the  heat  required  to  fuse  the  latter,  is  greater  than 
can  be  obtained  by  the  means  employed  for  melting  the 
former,  consequently,  if  it  were  used  for  purposes  of  this 
sort,  it  would  be  at  a  great  sacrifice,  as  the  scraps  and 
filings  removed  in  working  it  into  the  proper  forms,  would 
be  of  little  value,  or  at  any  rate,  they  could  not  readily 
be  re-converted  into  plate.  It  wou^l  not,  therefore,  be 
a  matter  of  much  economy  to  substitute  the  use  of  this 
metal  for  t'lat  of  gold. 

Although  the  manner  of  refivng,  alloying  and  manu- 
facturing gold  into  plate,  solder,  &c.,  may  not  be  regarded 
as  coming  properly  within  the  province  of  the  dentist,  A^et^ 
as  he  often  experiences  great  difficulty  in  procuring  them 
of  the  right  quality,  a  brief  description  of  these  several  pro- 
cesses will  not  prove  unacceptable  to  the  members  of  the 
professiiin.  Gold  in  its  pure  state,  or  when  free  from  alloy, 
i  too  soft  ai  d  yieldi  g  to  serve  as  a  suitable  support  for 
artificial  teeth,  and  if  it  contains  too  much,  or  an  improper 
alloy,  it  will  either  be  tarnished  or  blackened  by  the  secre- 


MANNER   OF   REFINING   AND    ALLOYING   GOLD.  691 

tions  of  the  mouth,  or  rendered  too  brittle  for  dental  pur- 
poses. It  is  of  the  utmost  importance  that  the  gold  used  in 
connection  with  artificial  teetli,  should  be  of  the  proper  fine- 
ness, and  possessed  of  the  requisite  ductility.  To  secure 
these  qualities,  it  is  necessary  to  know  the  kind  and  quantity 
of  metal  Ajith  which  it  is  alloyed  before  it  is  made  into 
plate  or  the  forms  necessary  for  the  purposes  for  which  it  is 
to  be  employed,  and  when  this  cannot  be  previously  ascer- 
tained, it  should  be  first  refined,  and  afterwards  proj)erly 
alloyed. 

The  scraps  and  filings  removed  in  shaping  and  reducing 
to  their  proper  size  and  form  the  various  pieces  of  gold  used 
in  the  construction  of  a  piece  of  dental  mechanism,  are  apt 
to  become  mixed  with  base  metals,  such  as  iron  from  the 
wearing  of  files,  and,  occasionally  small  particles  of  lead,  or 
tin.  If  these  are  melted  with  and  permitted  to  remain  in 
the  gold,  they  will  destroy  its  ductility,  and  render  it  unfit 
for  a  base  or  suj^port  to  artificial  teeth.  The  first  of  these 
metals  is  less  objectionable  than  either  of  the  others,  and 
may  always  be  removed,  before  the  gold  is  melted,  with  a 
magnet,  but  to  free  it  perfectly  from  the  others,  it  will  some- 
times be  necessary  to  refine  it  in  the  manner  presently  to  be 
described.  A  two-thousandth  part  of  tin  or  lead  destroys 
the  ductility  of  gold,  and  even  the  exposure  of  it  to  the 
fumes  of  red  hot  tin  or  lead,  renders  it  exceedingly  hard 
and  brittle.  Antimony,,  or  bismuth,  when  mixed  with  gold, 
exerts  upon  it  a  very  similar  effect. 

Platina,  united  witli  gold  in  certain  proportions,  while  it 
has  the  effect  of  hardening  the  latter  metal^  does  not  ma- 
terially affect  its  ductility,  but  the  affinity  of  the  alloy  for 
oxygen  is  so  great,  that  it  is  read'.ly  acted  upon  by  nitric 
acid.  But  for  this,  the  two  metals  combined  in  the  propor- 
tion of  fifteen  parts  of  gold  to  one  of  platina,  would  form 
an  exceedingly  useful  alloy  for  the  construction  o!'  spiral 
springs.  But  for  the  reason  just  mentioned,  it  cannot  be 
safely  used  for  this  purpose,  as  the  septic  (nitrou.s)  acid  of 
the  mouth,  would,  in  most  cases,  be  likely,  in  a  short  time, 


692  MANNER    OF   REFINIXG   GOLD. 

to  corrode  and  destroy  the  springs.  That  this  combination 
of  these  two  metals  should  be  thus  easily  acted  on  by  an 
agent  incapable  of  acting  on  either,  when  in  a  separate 
state,  may  appear  somewhat  remarkable,  but  it  is,  neverthe- 
less, true.  The  color  of  gold,  even  by  the  combination  of 
this  small  quantity  of  platina  with  it,  is  rendgred  much 
whiter  than  when  in  its  pure  state. 

In  view,  then,  of  the  importance  of  having  gold,  which  is 
to  be  placed  in  the  mouth,  of  the  right  quality,  every  den- 
tist, who  has  connected  with  his  practice  a  mechanical  lab- 
oratory, should  have  the  necessary  fixtures  for  melting  and 
working  this  metal  into  the  various  forms  required  for  den- 
tal I  )U;  poses.  The  princii)le  of  these  are,  a  small  furnace, 
crucibles^  ingot  moulds,  an  anvil  and  hammers,  a  rolling 
mill,  a  plate-gauge,  draw-jdate  and  bench,  for  drawing 
wire,  etc.     These  will  hereafter  be  described. 

MANXER   OF  REFINING  GULD. 

It  is  not  our  intention,  in  describing  the  manner  of  refin- 
ing gold,  to  enter  into  a  minute  detail  of  the  various  methods 
emploj'ed  for  assaying  this  metal,  but  to  point  out,  as 
briefly  as  possible,  the  manner  of  separating  it  from  the 
several  metals  with  which  it  is  most  frequently  combined. 

The  method  usually  employed  by  assayers  for  separating 
gold  from  silver,  is,  to  roll  the  alloy  out  into  very  thin  plates, 
and  put  it  in  nitric  acid  ;  this  will  dissolve  most  of  the  sil- 
ver, and  leave  the  gold  behind  in  the  form  of  a  brown  or 
black  calx.  This^  by  heating,  will  acquire  the  color  of  gold 
But  this  method  will  not  succeed,  unless  the  quantity  of 
silver  be  equal  to  two  or  three  times  that  of  the  gold.  When 
the  quantity  of  gold  is  greater  than  that  of  the  silver,  the  most 
of  the  former  may  be  separated  from  the  latter,  by  solution 
in  nitro-muriatic  acid.  But  a  perfect  separation  of  the  two 
metals  will  not  he  effected  in  eithef  case.  In  tlie  first,  a  re- 
siduum of  silver  will  remain  united  with  the  undissolved 
gold,  and  in  tlie  second,  a  residuum  of  gold  will  remain  with 


^ 


L 


MANNER    OF   REFINING   GOLD,  693 

the  undissolved  silver.  The  remaining  silver  may  he  re- 
moved hy  melting  the  gold  with  twice  its  we  ght  of  sul- 
phuret  of  antimony.  This  may  be  done  with  a  strong  heat 
in  a  covered  crucible,  and  after  the  gold  has  been  kept  in  a 
state  of  fusion  for  some  thirty  or  forty  minutes  it  should  be 
poured  out  into  an  ingot  mould,  and  separated  from  the  an- 
timony which  will  lie  at  the  top.  It  may  be  necessary  to 
melt  it  in  this  way  two  or  three  times,  adding,  each  time,  a 
less  quantity  of  antimony  ;  and  at  the  last  melting,  a  cur- 
rent of  air,  from  a  pair  of  bellows,  should  be  thrown  upon 
the  surface  of  tlie  fused  metal  to  evaporate  the  antimony, 
and  after  the  vapor  ceases  to  escape,  a  little  refined  nitrate 
of  potassaand  sub-borate  of  soda  should  be  thrown  into  the 
crucible.  It  should  then,  in  a  few  minutes,  be  poured  out, 
and  if  it  cracks  in  hammering  or  rolling,  it  should  be  again 
melted,  and  a  little  more  nitrate  of  potassa  and  sub-borate 
of  soda  tlirowu  on  it. 

Tliere  is  another  process  for  refining  gold,  employed  in 
some  of  the  mints,  called  cementation.  It  consists  in  first 
rolling  the  gold  out  into  exceedingly  thin  plates,  then  plac- 
ing it  with  a  mixture  of  four  parts  of  brick-dust,  one  of  sul- 
phate of  iron,  calcined  to  redness,  and  one  of  chloride  of 
soda,  in  a  crucible.  A  bed  of  this  mixture,  or  cementing 
powder,  is  first  placed  in  the  bottom  of  the  crucible  ;  tlie  gold 
is  then  ])ut  in  and  covered  with  it.  The  crucible  is  covered 
with  another  crucible,  the  joints  well  luted  with  clay,  and 
exposed  to  a  heat  gradually  raised  to  a  red  heat,  at  which 
elevation  of  temperature,  it  should  be  kept  from  twenty  to 
twenty-four  liours.  The  crucible  is  now  removed  from  the 
fire,  the  top  broken  off,  and  after  the  latter  has  cooled,  the 
gold  may  be  separated  from  the  cement  and  washed  with 
hot  water^  or  what  is  still  better,  boiled  in  hot  water.* 

The  kind  of  furnace  employed  for  melting  gold  may  be 
very  simple,  such,  for  example,  as  is  used  by  gold  and  sil- 
versmiths, or  the  one  invented  by  Dr.  Somerby,  in  connec- 

*  See  Chemistry  of  Arts,  vol.  ii,  pp.  545-6  and  550-1.  • 


694  MANNER   OF   REFINING   GOLD. 

tion  with  his  concentrated  blow-pipe.  But  in  tlie  absence 
of  either  of  these,  a  furnace  similar  to  4;he  one  used  by  the 
Ceylonese  goldsmiths  may  be  substituted.  This  consists  of 
a  small  low  earthen  pot,  filled  with  chafi",  or  saw-dust,  on 
which  a  little  charcoal  fire  is  made,  which  is  excited  with  a 
small  bamboo  blow-pipe,  about  six  inches  long,  the  blast  be- 
ing directed  through  a  short  earthen  pipe  or  nozel,  the  end 
of  which  is  placed  at  the  bottom  of  the  fire.*  By  this  sim- 
ple contrivance,  a  most  intense  heat,  greater,  it  is  said,  than 
is  required  for  melting  gold  or  silver,  may  be  obtained. 

For  separating  copper,  tin,  lead  or  zinc^  from  gold,  the 
following  simple  method  may  be  adopted  ;  put  the  gold  in  a 
clean  crucible,  covered  with  another  crucible,  having  a  small 
opening  or  hole  through  the  top  ;  lute  the  two  together 
with  clay,  place  them  in  a  bed  of  charcoal  in  the  furnace, 
ignite  the  coal  gradually  ;  afterwards  increase  the  combus- 
tion by  means  of  a  current  of  air  from  a  pair  of  bellows,  such 
as  are  usually  used  in  connection  with  small  furnaces  ;  after 
the  gold  has  melted,  throw  in  several  small  lumps  of  nitrate 
of  potassa  (saltpetre)  and  sub-borate  of  soda,  (borax,)  and 
keep  it  in  a  fused  state  for  thirty  or  forty  minutes,  then  sep- 
arate the  two  crucibles,  and  pour  the  metal  in  an  ingot 
mould  of  the  proper  size,  previously  warmed  and  oiled. 
Most  of  the  base  metals  will  be  dissipated  during  the  pro- 
cess of  fusion  in  the  form  of  vapor,  the  lead  escaping  into 
the  pores  of  the  crucible.  The  bichloride  of  mercury  (cor- 
rosive sublimate)  is  sometimes  used  instead  of  the  nitrate  of 
potassa,  for  the  jnirpose  of  dissii)ating  the  base  metals,  and 
often  with  more  certain  and  better  results.  If  the  gold 
cracks  on  being  hammered  or  rolled,  it  should  be  melted 
again,  and  more  nitrate  of  potassa,  and  sub-borate  of  soda 
thrown  into  it;  but  the  inside  of  the  crucible  should  be  well 
rubbed  with  the  latter,  before  the  metal  is  put  in.  It  is 
sometimes  necessary  to  repeat  this  process  several  times, 
and  if  the  gold  still  continues   brittle,  a  little  muriate  of 

*  Chemistry  of  the  Arts,  vol.  ii,  p.  551. 


4 


MANNER   OF   REFINING   GOLD.  695 

ammonia  (sal  ammoniac)  may  be  thrown  into  tlie  crucible 
when  tlie  gold  is  in  a  fused  state,  and  after  the  vapor  ceases 
to  escape,  the  metal  may  be  poured  into  an  ingot  mould, 
warmed  and  oiled  as  before  directed.  This  last  method  of 
treatment  will  make  the  gold  tough,  and  prevent  it  from 
cracking  under  the  hammer,  or  while  being  rolled,  if  it  be_, 
from  time  to  time,  properly  annealed. 

To  separate  platina  from  gold,  it  is  necessary  to  dissolve 
the  alloy  in  a  mixture  of  nitric  and  muriatic  acids,  and 
afterwards  to  pour  in  a  solution  of  muriate  of  ammonia, 
which  will  cause  the  former  metal  to  be  precipitated.  The 
acid  may  then  be  poured  into  another  vessel,  and  the  gold 
precipitated  by  pouring  a  solution  of  sulphate  of  iron  into  it. 

By  the  foregoing  methods  of  refining  gold,  sufficiently 
accurate  results  will  be  obtained  for  all  useful  practical  pur- 
poses in  mechanical  dentistry,  and  as  this  is  the  object  at 
which  the  author  aims,  he  does  not  deem  it  necessary  to  go 
into  a  minute  detail  of  the  various  complex  processes  em- 
ployed for  separating  the  several  metals  occasionally  found 
combined  with  the  one  under  consideration.  The  variation 
of  an  eighth  or  a  quarter  of  a  carat  in  the  fineness  of  the 
gold  employed  in  connection  with  artificial  teeth,  is  not  a 
matter  of  much  consequence.* 

*  The  method  of  procedure  pursued  by  Dr.  Elliot  for  refining  gold  is  as  follows  :  _ 
He  says,  "The  following  implements  are  necessary  for  this  purpose  :  a  small  draught 
furnace,  a  quantity  of  fine  hard-wood  coal,  a  clean  crucible,  with  a  sheet-iron  cov- 
er, a  light  crucible  tongs,  an  ingot  mould  made  of  soapstone,  a  little  nitrate  of  po- 
tassa,  carbonate  of  potassa,  borax  and  oil.  The  fireplace  of  the  furnace  should  be 
about  ten  inches  in  diameter,  and  eight  or  ten  deep  ;  this  should  be  connected  by 
means  of  a  pipe  with  the  chimney,  so  that  a  powerful  draught  may  be  made  to  pass 
through  the  coal.  A  blast  furnace  is  objectionable,  for  the  reason  that  the  bellows 
burns  out  the  coal  immediately  under  the  crucible,  and  it  is  therefore  constantly 
dropping  down,  which  is  not  the  case  with  the  draught  furnace;  besides,  the 
draught  furnace  produces  a  more  even  fire,  a  quality  equally  indispensable. 

"In  preparing  for  a  heat,  the  furnace  should  be  filled  about  half  full  of  coal,  and 
after  it  is  well  ignited,  it  should  be  consolidated  as  much  as  practicable  without 
choking  the  draught.  The  crucible  containing  the  metal  and  a  little  borax  may 
then  bo  set  on,  and  more  coal  placed  around  and  over  it,  the  door  of  the  furnace 
closed,  and  the  damper  opened  ;  it  should  remain  in  this  way  until  the  gold  is  per- 
fectly fused,  the  coal  may  then  be  removed  from  over  the  crucible,  and  a  bit  of  ni- 
trate of  potassa  dropped  in,  in  quantity  equal  to  the  size  of  a  pea  to  every  ounce  of 


696  MANNER   OF   ALLOYING   GOLD. 


ALLOYING    GOLD. 

Gold,  when  in  an  unalloyed  or  pure  state,  as  has  been 
before  stated,  is  too  soft  for  a  support  for  artificial  teeth, 
consequently,  it  has  been  found  necessary  to  combine  with  it 
soroe  other  metal,  in  order  to  harden  it.  Silver  and  copper 
are  the  alloys  most  frequently  employed.  Many  dentists 
prefer  the  former,  for  the  reason,  as  they  erroneously  sup- 
j)Ose,  that  it  does  not  increase  the  liability  of  gold  to  tarnish 
as  much  as  the  latter.  But  this  opinion  is  neither  sustained 
by  facts  nor  experience.  Gold,  when  alloyed  with  copper, 
unless  reduced  altogether  too  much  for  dental  purposes,  will 
resist  the  action  of  acids  as  effectually  as  when  alloyed  with 
silver,  and  the  former  renders  it  much  harder  than  the  lat- 

gold,  and  the  crucible  immediately  covered  with  a  plate  of  iron  ;  more  coal  may- 
then  be  placed  over  and  around  the  crucible,  and  the  gold  kept  in  a  fused  state  at 
a  high  temperature,  until  the  scoria  ceases  to  pass  off,  which  it  will  do  in  the 
course  of  five  or  six  minutes.  The  ingot  mould  having  been  previously  warmed, 
may  be  placed  in  a  convenient  position  for  pouring,  and  filled  about  half  full  of 
lamp  oil.  The  iron  cover  may  now  be  thrown  cfi' quickly,  the  crucible  seized  with 
the  tongs,  and  at  the  same  instant  another  small  bit  of  nitrate  of  potassa  should  be 
thrown  into  it,  and  the  gold  rapidly,  but  carefully  poured  into  the  mould. 

"The  ingot  always  cools  first  at  the  edges,  and  shrinks  away  from  the  middle  ; 
on  that  account  the  mould  should  be  a  little  concave  on  the  sides,  so  that  the  shrink- 
ing will  not  reduce  the  ingot  thinner  in  the  centre  than  at  the  edges. 

'•Moulds  of  the  btst  form  will  sometimes  produce  ingots  of  irregular  thickness; 
such  ingots  should  be  brought  to  a  uniform  thickness  under  the  hammer,  using  the 
common  callipers  as  a  gauge  ;  if  this  be  neglected,  the  plate  will  be  found  imper- 
fect at  those  points  where  the  ingot  was  thinnest.  The  plate  should  be  annealed 
occasionally  during  the  process  of  hammering  and  rolling,  and  should  be  reduced 
about  one  number  in  thickness  each  time  it  passes  between  the  rolls.  If  any  lead, 
tin  or  zinc  be  mixed  with  the  gold,  the  nitrate  of  potassa  must  be  used  in  much 
larger  quantities,  and  in  that  case,  it  is  better  to  let  the  button  cool  in  the  bottom 
of  the  ciucible;  then  break  the  crucible  and  melt  it  in  a  clean  one  for  pouring, 
using  borax  and  nitrate  of  potassa  in  very  small  quantities  for  the  last  melt. 

"In  case  the  subject  of  assay  be  in  the  form  of  fillings  or  dust,  a  magnet  should 
be  passed  through  it  so  as  to  remove  every  particle  of  iron,  and  then,  instead  of 
melting  it  with  borax,  it  should  be  melted  first  with  carbonate  of  potassa,  and  after- 
wards with  nitrate  of  potassa,  in  quantities  proportioned  to  the  necessities  of  the 
ease  as  before  directed  ;  carbonate  of  potassa  is  the  only  flux  that  will  bring  all 
the  smnll  particles  of  metal  into  one  mass  ;  without  it,  a  great  portion  of  the  gold 
will  be  found  among  the  scoria,  adhering  to  the  sides  of  the  crucible,  in  the  form 
of  small  globules.  The  process  of  refining,  answers  equally  as  well  for  silver  as 
gold," — Am.  Jour.  Dent.  Sci.,  vol.  vii,  pp.  71-2. 


MANNER   OF   ALLOYING   GOLD.  697 

ter.  Besides,  it  renders  the  gold  susceptible  of  a  higher 
and  more  beautiful  finish.  If,  therefore,  but  one  of  these 
metals  is  used,  copper  may  be  regarded  as  preferable  to  sil- 
ver, but  two  or  three  parts  of  the  former,  and  one  of  the 
latter,  constitutes  a  better  alloy  for  gold,  used  as  a  basis  for 
artificial  teeth^  than  either,  separately  from  the  other. 

The  gold  employed  in  mechanical  dentistry  by  most  prac- 
titioners, is  altogether  too  impure  for  the  purpose^  it  being 
not  more  than  from  fifteen  to  seventeen  carats  fine,  and 
sometimes  it  is  reduced  even  to  fourteen.  When  not  above 
these  standards  of  fineness,  it  is  discolored  by  the  buccal  se- 
cretions, and  it  imparts  an  exceedingly  disagreeable  taste  to 
the  mouth.  The  plate  which  is  to  serve  as  a  basis  for  arti- 
ficial teeth  should  never  be  reduced  below  twenty  carats,  and 
as  that  for  the  upper  jaw  does  not  require  to  be  more  than 
one-third  or  one-half  as  thick  as  that  of  the  lower,  the  gold 
for  the  latter  may  be  a  little  finer  than  that  employed  for 
the  former,  as  it  is  necessary  that  it  should  be  more  malle- 
able. The  following  standards  of  fineness  may  be  regarded 
as  the  best  that  can  be  adopted  for  gold  used  in  con- 
nection with  artificial  teeth. 

Plate  for  the  upper  jaw,  twenty  carats ;  for  the  lower, 
twenty-one,  and  for  clasps  and  wire  for  spiral  springs, 
eighteen.  In  reducing  perfectly  pure,  or  twenty-four  carat 
gold,  to  these  standards,  the  following  are  the  proper  pro- 
portions of  alloy  to  be  employed: 

1.  For  twenty  carat  gold:  take  20  dwts.  pure  gold,  3 
dwts.  fine  copper,  and  1  dwt.  silver. 

2.  For  twenty-one  carat  gold:  take  21  dwts.  pure  gold, 
2  dwts.  fine  copper,  and  1  dwt.  silver. 

3.  For  eighteen  carat  gold :  take  18  dwts.  pure  gold,  5 
dwts.  best  copper,  and  1  dwt.  silver. 

The  gold  should  be  first  melted  in  a  clean  crucible,  and 
as  soon  as  it  has  become  thoroughly  fused,  the  silver  and 
then  the  copper  may  be  thrown  in  with  two  or  three  small 
lumps  of  sub-borate  of  soda.  After  keeping  the  whole  in 
a  melted  state  for  some  five  or  ten  minutes,  it  may  be  poured 
45 


698  MANNER   OF   MAKING   SPRINGS. 

into  an  ingot  mould  of  the  proper  size,  previously  warmed 
and  oiled.  If  the  gold  cracks  during  the  process  of  ham- 
mering or  rolling,  it  may  be  melted  again,  and  a  few  small 
pieces  of  sub-borate  of  soda,  with  a  little  muriate  of  ammo- 
nia thrown  in.  In  five  or  ten  minutes,  it  may  be  recast  into 
an  ingot. 

When  scraps  and  filings  are  to  be  converted  into  plate, 
they  should  first  be  refined,  afterwards  properly  alloyed. 
This  may  also  be  necessary  with  all  gold  the  quality  or  fine- 
ness of  which  is  not  known,  but  with  national  coins  having 
a  known  fixed  standard,  this  will  not  be  necessary,  unless 
they  are  below  twenty-one  or  twenty  carats.  When  they 
are  above  these  standards  of  fineness,  a  sufficient  amount 
of  alloy  may  be  added  to  reduce  them  to  the  one  required. 

MANNER  OP  MAKING  SPRINGS  FOR  THE  SUPPORT  OP   ARTIFICIAL 

TEETH. 

The  springs  most  frequently  employed,  at  the  present 
day,  for  confining  artificial  teeth  in  the  mouth,  are  made  by 

Fig.  161. 


©       9 


winding  a  small  gtdd  v/ire  around  a  s])indle,  until  a  coil  of 
sufficient  length  has  been  formed.  The  wire  for  this  j)ur- 
pose  should  never  be  thicker  than  is  absolutely  necessary  to 
give  to  the  springs  the  requisite  degree  of  power,  and  is 
formed  by  forcing  a  piece  of  gold,  properly  alloyed  and 
previously  forged  into  a  small  oblong  shape,  through  a  series 


MANNER   OF   MAKING   SPRINGS. 


699 


of  progressively  diminished  holes  in  a  steel  plate,  like  the 
one  represented  in  Fig.  161,  until  the  requisite  fineness  is 
attained.  For  overcoming  the  adhesion  of  the  particles  of 
the  metal,  a  machine  called  the  draw-hench  is  required. 


Fig.  162. 


See  Fig.  162.  The  jaws  of  the  pincers  which  hold  the  ex- 
tremity of  the  wire,  for  pulling  it  through  the  successively 
diminishing  holes  of  the  plate,  are  cut  on  the  inside  like  a 
file.     While  the  plate  is  confined  at  one  end  of  the  bench, 


Fig.  163. 


the  pincers  are  attached  to  a  baud  wound  round  a  roller, 
turned  by  a  crank  at  tlie  other.     After  the  wire  has  been 


700  MANNER   OF   MAKING   SPRINGS. 

grasped,  the  crank  should  be  slowly  turned,  but  the  motion 
should  be  steady,  for  if  it  proceeds  irregularly,  it  will  cause 
inequalities  in  the  wire.  To  prevent  the  gold  from  becom- 
ing too  hard  and  brittle,  it  should  be  annealed  between  the 
successive  drawings. 

The  simplest  method  of  winding  the  wire  into  a  spiral 
spring,  is  to  secure  it  between  two  blocks  of  wood,  held  be- 
tween the  jaws  of  a  small  bench-vice.  The  upper  end  of 
the  wire  is  then  grasped  in  connection  with  a  small  spindle 
or  steel-wire,  the  size  of  a  small  knitting-needle,  six  or 
eight  inches  in  length,  by  a  hand-vice  or  sliding-tongs; 
the  spindle  resting  on  the  blocks  of  wood  is  made  to  revolve  by 
turning  the  hand-vice  or  sliding-tongs.  By  this  movement 
the  gold  wire  is  wound  firmly  and  closely  round  the  steel 
rod  or  spindle.     See  Fig.  163. 

Bat  by  means  of  the  machine  represented  in  Fig.  164, 
and  invented  by  Dr.  Howcott  and  Davidson,  dentists,  of 
Memphis,  Tenn.,  the  wire  maybe  wound  with  much  greater 
uniformity  and  accuracy.  This  is  the  most  perfect  contri- 
vance ever  employed  for  the  purpose.  It  is  simple  in  its 
construction^  and  the  great   superiority  which  it  possesses 

Fig.  164. 


over  the  other  means  employed  for  winding  wire,  consists  in 
the  accuracy  of  its  02)eration. 


MANNER    OF    MAKING   GOLD    PLATE. 


701 


MANNER    OP    MAKING    GOLD    PLATE. 


The  gold  after  being  melted  in  a  ^"'-  ^^^' 

clean  crucible,  well  rubbed  on  the 
inside  with  borax,  should  be  poured 
into  an  ingot  mould  of  the  proper 
length,  width  and  thickness  ;  then 
after  it  has  become  sufficiently  cool, 
it  may  be  placed  on  an  anvil,  and 
its  thickness  reduced  to  about  an 
eighth  of  an  inch,  with  a  hammer 
of  suitable  weight.  It  should  now 
be  well  annealed  by  being  placed 
in  the  furnace,  lightly  covered  with  small  pieces  of  char- 
coal and  heated  until  every  part  of  it  becomes  red.  It  may 
be  necessary  during  the  operation  of  hammering,  to  subject 
it  once  or  twice  to  this  process,  to  prevent  the  gold  from 
cracking,  and  if,  notwithstanding  this  precaution,  it  does 
crack,  it  should  be  again  melted,  and  in  addition  to  the 
borax,  a  little  muriate  of  ammonia  maybe  thrown  into  the 
crucible  as  soon  as  it  becomes  melted.  It  is  then  recast  into 
an  ingot,  and  forged  with-  ^'o-  i^^- 

out  danger  of  again  crack- 
ing unless  cooled  too  sud- 
denly. In  this  case  it  will 
be  thicker  at  tlie  sides  than 
in  the  centre,  and  may 
become  flawy  in  forging. 
This,  therefore,  should  be 
guarded  against  as  much 
as  possible,  by  cooling 
gradually . 

After  the  gold  has  been  reduced  to  the  thickness  just  men- 
tioned, and  well  annealed,  it  may  be  placed  between  the 
rollers  of  the  mill,  previously  so  adjusted,  as  to  be  the  same 


Fio.  165.  A  slidiDg  ingot  mould.     It  may  be  made  of  iron  or  soap-stone. 


702 


MANNER   OP  MAKING   GOLD   PLATE. 


Fia.  167.  distance  apart  at  both  ends,  and 

not  so  near  to  each  other  as  to  re- 
quire a  great  effort  to  force  it  be- 
tween them.  The  rollers,  how- 
ever, should  be  brought  a  little 
nearer  to  each  other  every  time 
the  plate  is  passed  between  them, 
and  during  this  process  they 
should  be  kept  well  oiled,  so  that 
there  may  be  as  little  friction  as 
possible. 

Rolling  mills  for  gold  are  vari- 
ously constructed.  Some  are  very 
simple,  while  others  are  quite 
complex,  having  a  great  deal  of 
machinery  connected  with  them. 
The  rollers  also  vary  in  length. 
For  the  gold  plate  used  by  den- 
tists, they  need  not  be  more  than 
three  or  three  and  a  half  inches 
long.  A  mill  like  the  one  repre- 
sented in  Fig.  166  will  be  found 
to  answer  all  practical  purposes. 
It  is  worked,  as  may  be  perceived, 
by  two  cranks,  one  to  each  roller, 
but  fixovd  on  opposite  sides  of  the 
mill,  so  that  two  persons  are  re- 
quired to  turn  them. 

AVhile  the  gold  is  being  rolled, 
it  should  be  frequently  annealed. 
The  thickness  of  the  plate  may  be  determined  by  a  gauge 
plate,  like  the  one  represented  in  Fig.  167.  That  which 
is  to  serve  as  a  basis  for  artificial  teeth  for  the  upper 
jaw,  may  be  reduced  until  it  fits  the  gauge  at  25  or  26  ; 
for  the  lower  jaw,  21  or  22  ;  for  backings  for  the  teeth_, 
at  24  ;  and  plate  for  clasps,  at  23.     It  is  sometimes  neces- 


MANNER   OF   MAKING   GOLD   SOLDER.  T03 

sary,  however,  to  vary  the  thickness  of  the  plate  used  for 
these  several  purposes  ;  as  for  example,  when  the  whole 
alveolar  border  and  a  portion  of  the  roof  of  the  mouth  is  to 
be  covered,  it  may  be  a  little  thinner  than  when  applied 
only  to  a  small  surface.  When  very  wide  clasps  too,  are 
employed^  it  is  not  necessary  that  the  gold  should  be  as  thick 
as  is  required  for  narrow  ones.  But  these  are  matters  which 
the  judgment  of  the  dentist  alone  can  properly  determine, 
and  consequently  no  rules  can  be  laid  down  upon  this  sub- 
ject, from  which  it  will  not  sometimes  be  necessary  to 
deviate. 

The  gauge  plate  represented  above  has  only  26  numbers  ; 
some  are  made  with  from  four  to  fourteen  more. 


MANNER  OF  MAKING  GOLD  .BOLDER. 

In  making  gold  solder,  the  metals  employed  for  the  pur- 
pose, if  not  pure,  should  be  refined  separately.  Unless  this 
is  done,  it  would  be  difficult  to  ascertain  their  relative 
purity,  which  should  be  known  to  insure  the  desired  result. 
The  gold  is  placed  in  a  clean  crucible  with  a  little  borax, 
and  as  soon  as  it  has  become  perfectly  melted,  the  silver,  and 
afterwards  the  copper,  is  added.  When  all  are  melted,  the 
alloy  may  be  immediately  poured  into  an  ingot  mould,  pre- 
viously warmed  and  oiled. 

The  process  of  hammering  and  rolling  the  solder  is  the 
same  as  that  described  for  gold  plate. 

The  solder  employed  for  uniting  the  various  parts  of  a 
piece  of  dental  mechanism,  should  be  sufficiently  fine  to 
prevent  it  from  being  easily  acted  on  by  the  secretions  of  the 
mouth.  Either  of  the  following  recipes  will  be  found  well 
adapted  to  the  purpose  : 


704  MANNER   OF   MAKING   GOLD   SOLDER.  {I 

FINE    FLOWING    GOLD    SOLDER.  , 

RECIPE,  NO.  1. 

2  dwts.  22  carat  gold, 
16  grs.  fine  silver, 
12  grs.  roset  copper. 

RECIPE,    NO.  2. 

1  dwt.  15  grs.  22  carat  gold, 
16  grs.  fine  silver^ 
12  grs.  roset  copper. 

The  following  makes  ratlier  finer  solder  than  either  of 
the  above,  and  although  it  requires  a  little  stronger  blast  to 
melt  it,  it  flows  very  freely. 

FINE    FLOWING    GOLD    SOLDER. 

RECIPE,  NO.   3. 

6  dwts.  pure  gold, 
2  dwts.  roset  copper, 
1  dwt.  fine  silver. 

By  adding  two  or  three  grains  of  spelter^  solder,  finer 
than  that  made  by  either  of  the  foregoing  recipes,  may  be 
employed  without  any  increase  of  heat.  It  will  also  have  a 
finer  gold  color,  but  it  is  apt  to  impart  to  the  piece  a  brassy 
taste,  and  for  this  reason  the  author  rarely  uses  it.  Several 
other  recipes  might  be  added,  but  the  foregoing  are  sufiS- 
cient. 


CHAPTER    SEVENTH. 

WAX  AND  PLASTER  OF  PARIS  IMPRESSIONS  OF  THE 
MOUTH,  PLASTER  MODELS-ALSO,  METALLIC  MODELS 
AND  COUNTER-MODELS. 

In  the  construction  of  a  dental  substitute  mounted  on  a 
base,  it  is  necessary  to  obtain  an  exact  model  of  the  parts 
iijion  which  it  is  to  rest,  and  to  which  it  is  to  be  attached, 
but  before  this  can  be  done,  a  perfect  impression  in  wax,  or 
some  other  soft  and  yielding  substance,,  must  be  procured. 
The  manner  of  obtaining  this  is  as  follows. 

WAX    IMPRESSIONS. 


Fig.  168. 


Fill  a  frame  of  suitable  dimen- 
sions^ like  the  one  represented  in 
Fig.  168,  made  of  silver  or  tin, 
liiiiililiiil^  MiiliiilB  "^^^^^'^  white  or  yellow  wax,  softened 
in  warm  water  or  by  a  fire,  until 
it  is  of  the  consistency  of  dough, 
or  solt  putty  ;  then  put  it  in  the 
mouth  with  the  wax  facing  the 
jaw  to  be  supplied  with  artificial 
teeth,  and  press  it  carefully  against 
it,  covering  the  whole  of  the  va- 
cant space  and  the  adjoining  teeth 
as  far  back  as  it  may  be  necessary 
to  extend  the  plate.  The  pressure 
on  the  frame  should  be  sufficiently  great  to  imbed  the  teeth 
and  the  alveolar  ridge  completely  in  the  wax.     The  frarat 


706 


MANNER   OF   PROCURING   A   WAX   IMPRESSION. 


should  be  held  steadily  in  the  hand  of  the  operator,  pressing 
upon  every  part  of  it  alike.  The  wax  is  pressed  up  against 
the  gums  on  each  side  with  the  finger,  so  that  an  exact  im- 
pression may  he  obtained  of  all  the  depressions  and  protu- 
berances of  the  parts  on  which  the  plate  is  to  rest,  and  of 
the  remaining  teeth.  On  the  removal  of  the  frame  and  wax 
from  the  mouth,  the  greatest  precaution  is  necessary  to  pre- 
vent injuring  or  altering  the  shape  of  the  impression. 

Fig.  169.  Every  dentist  should    be    supplied 

with  several  of  these  frames,  differing 
in  size,  so  that  he  may  never  be  at  a 
loss  for  one  of  the  right  dimensions. 
When  an  impression  of  only  one  side 
of  the  mouth  and  the  front  part  of  the 
alveolar  ridge  is  required,  a  frame 
like  the  one  represented  in  Fig.  169 
will  be  found  most  convenient,  but 
when  such  are  used,  it  is  necessary  to 
have  one  for  each  side  of  the  jaw. 

Dr.  Elliot  recommends  that  the 
wax-frame  be  ''formed  by  being  struck 
up  between  a  model  and  counter-model,  in  the  same  way 
that  a  gum  plate  is  fitted  to  the  mouth."*  Wax-holders, 
thus  formed,  would,  doubtless,  be  more  convenient  than 
those  just  described,  but,  with  care,  an  accurate  impression, 
in  most  cases,  can  readily  be  obtained  with  either. 

In  several  cases,  however,  since  the  publication  of  the 
second  edition  of  this  work,  we  have  been  compelled  to  con- 
struct a  wax-holder  in  the  manner  as  described  by  Dr.  E., 
with  which  we  readily  succeeded  in  obtaining  a  perfect  im- 
pression, after  having  previously  made  several  unsuccessful 
attempts  to  procure  them  with  the  ordinary  wax-holders. 

After  removing  the  impression  from  the  mouth,  oil  should 
be  applied  to  it  with  a  camel's-hair  pencil  or  brush,  and  a 
wire  about  three-fourths  of  an  inch  long,  stuck  into  the 


*  American  Journal  of  Dental  Science,  vol.  v,  p.  90. 


MANNER   OF   PEOCURING   A   WAX   IMPRESSION.  707 

centre  of  the  bottom  of  each  cavity  made  in  the  wax  by  the 
teeth  next  the  vacant  space^  and  those  to  which  the  clasps 
are  to  be  applied,  to  prevent  the  liability  of  the  plaster  teeth 
from  being  broken. 

Fig.  170. 


The  wax  impression,  prepared  in  this  manner,  will  pre- 
sent the  appearance  exhibited  in  Fig.  170.  It  is  scarcely 
necessary  to  add,  that  unless  the  impression  is  j^erfect,  it 
will  be  impossible  to  fit  a  plate  to  the  parts  of  the  mouth  to 
which  it  is  to  be  applied  with  a  sufficient  degree  of  accuracy 
to  be  worn  with  impunity. 

Dr.  J.  A.  Cleaveland  contrived  a  set  of  wax-holders, 
admirably  adapted  for  taking  impressions,  both  of  the  lower 
and  upper  jaw.  Those  for  tbe  upper  jaw,  encase  the  alveo- 
lar border,  and  cover  the  roof  of  the  mouth  more  perfectly 
than  the  common  wax-holder,  possessing  the  advantages  of 
the  one  recommended  by  Dr.  Elliot,  without  subjecting  the 
operator  to  the  inconvenience  and  loss  of  time  of  making 
one  for  each  individual  case.  By  having  three  holders  for 
the  upper  jaw,  each  varying  in  size  from  the  other_,  one  will 
be  found  to  fit  almost  any  case  which  may  occur,  with  suffi- 
cient accuracy  for  all  practical  purposes.  For  the  purpose 
of  insuring  a  perfect  impression  in  those  cases  wliere  the 
alveolar  border  is  very  deep,  the  author  has  a  hole  cut 
through  the  centre  of  each,  as  seen  in  Fig.  171,  to  enable 


T08 


MANNER   OF   PROCURING   A   WAX  IMPRESSION. 


him  to  press  the  wax  up  against  the  anterior  part  of  the 
roof  of  the  mouth  with  the  finger. 

For  the  lower  jaw,  Dr.  Cleavcland  employs  two  wax-hold- 
ers— one  for   taking  impressions  where  six   or  eight  of  the 

Fig.  171.  Fig.  172. 


front  teeth  are  remaining,  and  the  other  for  taking  impi-es- 
sions  of  the  alveolar  border  in  which  there  are  no  teeth. 
Each  has  a  joint  in  the  cen- 
tre, so  that  it  can  be  made  ^'*''  ^^^" 
wider  or  narrower  at  plea- 
sure, to  suit  the  size  of  the 
jaw.  Without  the  central 
joint  or  hinge,  a  greater 
number  of  holders  are  re- 
quired, three  of  each  kind, 
and  each  differing  in  size 
from  the  other,  will  affoid 
sufficient  variety  to  enable 
the  operator  to  take  an  im- 
pression of  almost  any  jaw. 
In  Fig.  172  is  represent- 
ed one  of  Dr.  Cleaveland's 
wax-holders  for  taking   an  impression  of  the  alveolar  bor- 


IMPRESSIONS   IN   PLASTER   OF   PARIS.  Y09 

der  without  teetli,  and  witliout  the  central  joint ;  and  in 
Fig.  173,  is  seen  an  engraving  of  one  designed  for  tlie  pro- 
curement of  an  impression  of  a  lower  jaw  in  which  six  or 
eight  of  the  front  teeth  are  remaining. 

There  are  many  cases  in  which  it  is  impossible  to  remove 
a  wax  impression  from  the  mouth  without  injury.  In  such 
cases  plaster  of  paris  may  be  substituted.  With  this,  a  sat- 
isfactory result  may  always  be  obtained.* 

l^LASTER   OF   I'AUIS   IMPRESSIONS. 

Plaster  of  paris,  gypsum  or  sulphate  of  lime,  consists  of 
28  parts  of  lime  ;  40  of  sulphuric  acid,  and  18  of  water. 
When  exposed  to  a  heat  of  400°  Fahr.  the  water  of  the 
gypsum  escapes.  After  being  properly  calcined  and  pulver- 
ized, if  mixed  with  water  to  the  consistence  of  thin  batter  or 
cream,  it  hardens  in  a  few  minutes,  by  a  species  of  crystalli- 
zation, and  acquires  great  solidity.  During  the  first  part 
of  the  process  of  consolidation,  it  expands,  by  the  absorption 
of  the  water,  so  as  to  fill  the  small  depressions  in  any  mould 
in  which  it  may  be  poured. 

But  there  is  a  great  difference  in  the  quality  of  plaster  of 
paris.  That  used  for  taking  impressions  and  models  of  the 
mouth  should  be  of  the  best  description,  well  calcined,  finely 
pulverized,  and  jmssed  througli  a  sieve  previously  to  being 
used. 

In  taking  a  plaster  impression  of  the  mouth,  tlie  first 
thing  to  be  done,  is  to  place  a  rim  of  wax,  previously  soft- 
ened in  warm  water,  or  by  a  fire,  around  the  rim  of  a  wax- 
holder  of  the  proper  size,  closing  up  the  open  ends,  so 
that  when  applied,  it  will  completely  encase  the  alveolar 
ridge  of  the  upper  jaw,  tlien  fill  it  with  a  thin  batter,  made 
of  calcined  plaster  of  paris  and  water,  and  before  it  begins 
to  concrete^  put  it  into  the  mouth,  and  apply  it  to  the  upper 

*  The  idea  of  taking  impressions  of  the  mouth  with  plaster  of  paris,  originated  , 
we  belitve,  almost  simultaneously  with  Drs.  Westcott,  Dunning,  and  Bridges. 


YIO  IMPRESSIONS  IN   PLASTER   OF   PARIS.. 

alveolar  border,  and  press  it  upwards,  until  a  suflficiently 
deep  and  accurate  impression  is  made  of  the  ridge,  remain- 
ing teeth  if  there  are  any_,  and  anterior  portion  of  the  roof 
of  the  mouth.  In  doing  this,  it  may  be  necessary  to  pass 
the  fore-finger  around  on  the  outside  and  inside,  pressing 
the  plaster  gently  against  the  parts.  An  accurate  impres- 
sion having  been  obtained,  it  sliould  remain  in  the  mouth 
two  or  three  minutes,  or  long  enougli  for  the  plaster  to 
harden,  when  it  may  be  removed.*  This,  however,  should 
be  done  with  great  care  to  prevent  cracking  or  injuring 
the  impression,  and  some  difficulty  is  occasionally  experi- 
enced in  detaching  it  from  the  mouthy  as  the  suction  or  at- 
mospheric pressure  is  often  so  considerable,  as  to  make  it 
adhere  with  great  tenacity.  When  this  is  the  case,  one 
side  should  be  first  gently  depressed,  and  if  it  cannot  be 
readily  loosened  at  one  point,  another  and  another  may  be 
tried  until  some  one  is  made  to  yield;  when  the  whole  may 
be  easily  removed. 

A  correct  plaster  impression  having  been  obtained,  the 
edges  are  smoothly  trimmed^  and  after  it  has  become  per- 
fectly dry,  it  is  oiled  or  varnished  before  it  is  used  fur  the 
procurement  of  a  model. 

The  method  of  obtaining  a  transfer  of  the  alveolar  ridge, 
recommended  by  M.  Desirabode,  will  always,  with  proper 
care,  secure  the  most  accurate  and  successful  results.  It 
consists,  after  having  obtained  a  metallic  model  and  coun- 
ter-model, in  striking  up  a  lead  plate,  trimming  it  to  the 
proper  size,  and  adjusting  it  with  the  finger  to  the  alveolar 
border,  until  it  is  made  to  fit  every  part  with  'perfect  accu- 
racy. It  is  then  carefully  removed,  and  used  instead  of  the 
original  wax  impression,  for  the  procurement  of  a  second 
plaster  model.  From  this  last,  new  metallic  castings  are 
obtained,  and  from  which  a  jierfect  atmospheric  pressure  or 
suction  plate  may  be  procured. f 

*  The  solidification  of  the  plaster  will  be  hastened  by  adding  a  little  salt  or  sul- 
phate of  potash. 

t  Vide  -Vauveaux  Elements  Complets  de  la  Science  et  dc  I'art.  Du  Dentiste,  t.  2, 
pp.  G36-7. 


MANNER   OF   PROCURING   A   PLASTER   MODEL,  711 


PLASTER     MODELS. 

The  impre.ssion.  whether  taken  in  wax  or  plaster,  is  first 
oiled,  then  filled  with  a  thin  paste  or  batter  made  of  the 
test  calcined  plaster  of  paris  and  water.  This  is  at  first 
poured  in  while  it  is  quite  thin,  and  with  great  care,  until 
the  impressions  made  by  the  teeth,  if  there  are  any  remain- 
ing in  the  jaw,  are  filled  ;  after  which,  the  batter  may  be 
allowed  to  thicken  a  little  before  the  remainder  of  the  im- 
pression is  filled  ;  it  is  then  poured  on  until  the  plas- 
ter is  raised  an  inch  or  an  inch  and  a  half  above  the  im- 
pression. 

Fig.  174. 


After  the  plaster  has  sufficiently  hardened,  it  may  be 
trimmed,  and  after  softening  th.e  wax  in  warm  water,  or  by 
a  fire,  it  is  removed  from  it.  The  same  impression  can 
sometimes  be  used  a  second  or  third  time,  but  lest  the  shape 
of  it  should  be  altered  in  tlic  removal  of  the  model,  a  du- 
plicate impression  may  be  taken.  The  plaster  model  may 
be  shaped  with  a  knife,  until  it  presents  an  appearance 
something  like  that  represented  in  Fig.  174,  that  a  me- 
tallic cast  obtained  from  it  may  be  easily  withdrawn  from 
an  impression  of  the  same  or  a  similar  material. 


712 


IdANNER   OF   PROCURING  A   PLASTER  MODEL. 


The  model,  after  having  heen  thus  trimmed,  should  have 
several  coats  of  shellac  or  sandarach  varnish  applied  to  it 
with  a  small  brush_,  to  give  it  a  smooth,  hard  and  polished 
surface.  This  will  prevent  it  from  wearing  away  by  use, 
and  render  it  more  pleasant  to  the  touch  of  the  hand.  The 
sandarach  varnish  is  preferable  to  the  shellac,  as  it  is  more 
transparent,  and,  consequently,  does  not  color  the  plaster. 
It  may  be  made  in  the  following  manner  :  take  sandarach, 
§  V,  elemi,  |  i,  digest  in  one  quart  of  alcohol,  moderately 
warm,  until  dissolved,  then  add  Venice  turpentine,  §  ij. 
This  is,  perhaps,  as  good  a  varnish  as  can  be  used  for  plas- 
ter models.  It  is  easily  prepared,  but  in  warming  the  al- 
cohol, some  care  is  necessary  to  prevent  it  from  taking  fire. 

The  sandarach  shouid  be  of  the  most  transparent  quality, 
and  washed  in  water  before  being  put  into  the  alcohol. 


^'0-  i''^-  For    striking   up   a   plate 

with  the  outer  edge  turned 
up,  a  groove,  about  an  eighth 
of  an  inch  deep  is  formed 
around  the  outside  of  the 
plaster  model,  where  it  is  de- 
signed that  the  edge  of  the 
base  shall  terminate  on  the 
alveolar  border,  by  the  ap- 
plication of  yellow  wax,  pre- 
viously softened,  which  is  af- 
!;  terwards  cut  away  witli  a 
knife  until  a  groove  of  the 
proper  shape  is  formed.  A  plaster  model  of  the  upper  jaw 
thus  prepared,  is  represented  in  Fig.  175.  A  plate  swaged 
with  dies,  from  such  a  model,  is  only  used  for  mounting 
gum  or  block  teeth.  A  dental  substitute  with  a  base  of 
this  kind  is  stronger  than  a  simple  plate  and  is  susceptible 
of  a  more  beautiful  finish. 

For  a  lower  set  of  block  teeth,  the  edge  of  the  plate  may 
be  turned  up  all  the  way  round.     But  rimming  teeth,  as  it 


MANNER   OF   PROCURING   A   PLASTER   MODEL. 


713 


is  termed  in  mechanical  dentistry,  which  consists  in  solder- 
ing a  narrow  strip  of  gold  to  the  outer  edge  of  the  plate  in 
such  a  manner  as  to  cover  the  outer  surface  of  the  extrem- 
ities of  the  teeth  or  edge  of  the  blocks  near  the  base,  is  on 
some  accounts,  preferable  to  a  plate  with  a  turned  edge. 
The  manner  of  doing  this,  will  be  described  in  the  chapter 
on  porcelain  block  tooth. 

Fig.  176. 


It  sometimes  happens,  when  the  alveolar  ridge  is  very 
deep,  that  the  lower  edge  of  the  arch  inclines  outwardly  so 
much  as  to  make  the  span  of  it  here  considerably  greater 
than  it  is  a  quarter  or  half  an  inch  higher  up.  In  this  case, 
if  sand  be  used  in  procuring  a  metallic  model,  it  is  difficult 
to  remove  the  plaster  without  injuring  the  impression  made 
in  the  sand.  To  obviate  which,  the  plaster  model  is  so  con- 
structed as  to  consist  of  three  pieces,  or  sections,  in  the  man- 
ner as  represented  in  Fig.  176,*  which  however,  only  shows 
two  sections  of  the  model.  After  the  tliree  are  put  togeth- 
er, in  the  manner  as  shown  in  Fig.  177,  it  may  be  pressed 
in  the  sand  until  a  good  impression  is  made,  and  afterwards 

*  Dr.  G.  E.  Hawes,  of  New  York  has  indented  a  moulding  flask,  by  the  use  of 
which,  the  plaster  model  may  be  taken  from  the  sand  without  injuring  the  impres- 
sion. A  description  of  this  will  bo  given  when  we  come  to  treat  of  the  manner 
of  procuring  a  metallic  model.  When  it  becomes  necessary  to  obtain  metallic  cast- 
ings for  the  construction  of  appliances  for  remedying  irregularity  of  thetectk, 
this  flask,  is  often  very  valuable. 

46 


714  METALLIC   MODEL   AND   COUNTER-MODEL. 

removed  separately.  Dr.  Westcott^  we  believe,  was  the 
first  to  introduce  the  use  of  this  description  of  plaster  model, 
which  may  be  procured  by  first  filling  the  wax  impression 
with  the  plaster  as  in  the  manner  before  described  ;  this  is 
then  removed,  and  about  one-third  from  each  side  trimmed 
ofi",  leaving  the  lower  surface  wider  than  the  upper.     This 

Fig.  177. 


^is:^«\lW"%^>.. 


done^  it  is  replaced  in  the  impression,  and  filled  up  on  each 
side  with  plaster  as  in  the  first  instance  ;  after  the  last  has 
consolidated,  the  model  is  properly  trimmed,  and  when  it 
has  become  perfectly  dry,  varnished. 

A  METALLIC  MODEL  AND  COUNTER-MODEL. 

Various  methods  have  been  adopted  for  procuring  metal- 
lic models  and  counter-models,  but  the  two  following  are 
all  which  the  author  deems  it  necessary  to  describe.  One  of 
these  consists  in  pouring  melted  metal  in  an  impression 
made  in  sand  with  the  plaster  model.  By  this  means  a 
metallic  model  is  procured,  and  the  female  or  counter-mod- 
el obtained  either  by  immersing  this  in,  or  pouring  melted 
metal  on  it.  The  other  consists  in  making  the  counter- 
model  first,  by  either  immersing  the  plaster  model  in,  or 
pouring  melted  metal  on  it,  and  afterwards  obtaining  the 
male  model  by  pouring  melted  metal  in  this. 


METALLIC   MODEL   AND   COUNTER-MODEL.  715 

When  they  are  to  be  obtained  by  tbe  first  method,  a  box 
is  required  about  six  inches  square  and  three  or  four  inches 
deep.  This  is  filled  with  fine  sand,  such  as  is  employed  in 
brass  and  iron  founderies.  After  this  has  been  slightly 
dampened,  the  plaster  model  is  pressed  in  it  to  the  depth  of 
an  inch  or  an  inch  and  a  half,  leaving  a  portion  of  it  un- 
imbedded,  that,  at  the  proper  time,  it  may  be  readily  re- 
moved. The  sand  is  thoroughly  packed  on  every  side  of  the 
plaster  model,  which,  after  this  has  been  done,  is  gently 
tapped  several  times  with  some  light  instrument  or 
hammer,  for  the  purpose  of  starting  or  detaching  it  a  little 
from  the  matrix,  and  then  carefully  removed.  If  the  model 
be  composed  of  three  pieces,  the  middle  section  is  first  re- 
moved, and  afterwards  the  two  others. 

A  shallow  furrow  or  groove,  of  about  an  inch  in  length, 
is  now  formed  in  the  sand,  on  one  side  of  the  mould  leading 
to  it,  and  both  the  furrow  and  mould  are  then  encircled 
with  a  rim  of  sheet  iron  of  about  three  inches  in  diameter, 
and  an  inch  and  a  quarter  in  width.  If,  in  the  meantime, 
any  particles  of  sand  have  fallen  into  the  mould,  they  may 
be  removed  by  blowing  gently  into  it. 

The  mould  being  now  prepared,  the  metal  to  be  em- 
ployed for  the  casting  may  be  put  in  a  tolerable  thick 
wrought  iron  ladle,  and  melted  either  in  a  common  fire  or 
furnace.  If  brass  is  used,  the  latter  will  be  required  to 
melt  it,  but  if  zinc,  block  tin  or  lead,  a  common  fire  will 
afford  sufficient  lieat.  After  the  metal  has  become  thorough- 
ly melted,  it  is  poured  on  the  inside  of  the  ring  into  the 
furrow  formed  in  the  sand,  when  it  will  immediately  flow 
into  the  mould.  It  is  necessary  to  convey  the  melted  metal 
into  the  mould  in  this  way  to  prevent  the  liability  to  injury 
which  it  might  sustain  by  pouring  directly  into  it. 

If  zinc  or  block-tin  is  used,  a  suflBcient  quantity  may 
be  melted  to  fill  nearly  the  whole  of  the  ring,  but  if  brass 
is  employed,  it  will  only  be  necessary  to  fill  the  mould  in 
the  sand.  It  is  only  when  a  very  thick  plate  is  to  be  struck 
up  or  an  encasement  to  be  placed  on  one  or  more  of  the  natu- 


710 


METALLIC   MODEL    AND   COUNTER-MODEL. 


ral  teeth  tliat  brass  is  required.  '  For  all  ordinary  purposes, 
either  of  the  two  first  metals  will  answer.  The  first  is 
usually  employed  for  the  male,  and  the  second  for  the  fe- 
male model. 

But  if  the  plaster  model  is  used  in  one  piece,  and  the 
shape  of  it  is  such  that  it  cannot  be  drawn  without  dragging 
more  or  less  of  the  sand  with  it,  the  moulding  flask  of  Dr. 
G.  E.  Hawes,  represented  in  Figs.  178,  179  and  180,  may 
be  employed. 


Fig.  178. 


Fig.  179. 


Fig.  180. 

The  manner  of  using  it  is  thus 
described  by  Dr.  C.  C.  Allen: 
"If  the  model  be  considerably 
smaller  than  the  space  between 
the  flanges  projecting  in  towards 
it,  small  slips  of  paper  may  be 
placed  in  the  joint  extending  to 
the  sides  of  the  model,  to  part  the  sand  when  opening  the 
flask,  for  the  removal  of  the  pattern.  The  sand  may  now 
be  transferred  around  the  pattern  up  to  the  most  prominent 
part  of  the  gum,  and  it  should  be  finished  smoothly  around 
it,  slightly  descending  towards  the  model,  so  as  to  form  a 
thick  edge  of  sand  for  the  more  pericct  parting  of  the  flask. 
The  sand  and  face  of  the  model  must  now  be  covered  with 
dry  pulverized  charcoal,  sifted  evenly  over  the  whole  sur- 
face.    When  this  is  done,  the  upper  section  of  the  flask  is 

Fig.  178.     The  lower  section  of  the  flask,  slightly  opened  to  show  joints.    Fig. 
179,  the  upper  section.     Fig.  180,  the  lower  section  closed,  and  confined  by  a  pin,        • 
with  the  plaster  model  placed  in  it. 


METALLIC   MODEL   AND   COUNTER-MODEL.  71*7 

placed  over  the  lower,  and  carefully  filled  with  sand.  It  is 
then  raised  from  the  lower  one,  which  may  then  he  parted 
by  removing  the  long  pin,  and  the  model  gently  taken  away. 
When  closed,  and  the  two  put  together  again  and  inverted, 
it  is  ready  to  receive  the  melted  metal."* 

After  the  casting  has  cooled,  it  maybe  removed,  or  rather 
turned  over,  so  that  the  part  presenting  a  transcript  of  the 
plaster  model  shall  he  upwards,  while  the  remainder  is 
buried  in  the  sand.  The  casting  thus  placed,  is  encircled 
with  the  ring  first  employed,  aiid  if  the  casting  be  made  of 
block-tin,  it  is  covered  with  a  thin  coating  of  whiting, 
mixed  with  water,  until  it  is  of  the  consistence  of  cream. 
This  may  be  put  on  with  a  camel' s-hair  pencil,  and  after  it 
has  become  perfectly  dry,  a  sufficient  quantity  to  fill  the 
ring,  of  block-tin  or  lead,  may  be  melted  in  the  ladle  as  be- 
fore directed,  and  when  its  temperature  has  become  so  much 
reduced  as  to  not  to  char  or  even  discolor  white  paper,  it 
may  be  immediately  poured  into  it. 

If  the  last  metal  bo  poured  into  the  ring  while  it  is  at  a 
higher  temperature,  or  if  the  precaution  of  covering  the  ex- 
posed part  of  the  first  casting  with  whiting,  is  not  used,  the 
two  will  be  liable  to  unite.  Even  when  zinc  is  used  for  the 
first  casting,  there  is  danger  of  fusing  it  if  the  metal  poured 
on  be  too  hot.  When  the  last  metal  used  requires  as  high 
or  nearly  as  high  a  heat  to  melt  it  as  the  first,  an  accident 
of  this  sort  is  still  more  liable  to  occur,  unless  great  care  is 
taken  to  prevent  it. 

The  gas  generated  by  the  decomposition  of  the  water  in 
the  sand,  sometimes  collects  under,  or  diffuses  itself  through 
the  metal,  and  renders  the  casting  more  or  less  imperfect. 
This,  in  most  instances,  may  be  prevented  by  pouring  the 
metal  slowly,  or  by  making  a  small  opening  through  it  with 
a  wire  for  its  escape,  before  it  has  congealed. 

After  the  last  metal  has  cooled,  the  castings  may  be  sepa- 
rated, and  if  perfect,  they  are  ready  for  use. 

By  the  second  method  of  procedure,   the  use  of  sand  is 

*  New  York  Dental  Recorder. 


718  METALLIC   MODEL   AND   COUNTER-MODEL. 

wholly  dispensed  witli,  and  this,  for  the  reason,  that 
smoother  castings  may  he  secured^  is,  in  most  cases,  prefer- 
ahle  to  the  first.  It  consists  in  pouring  melted  lead  into  a 
sheet  or  cast  iron  cup  or  box,  of  about  three  and  a  half  or 
four  inches  in  diameter,  and  three  inches  deep,  until  it  is 
half  full,  and  immediately  immersing  so  much  of  the  plas- 
ter model  in  it  as  represents  the  shape  of  the  alveolar  ridge 
and  remaining  teeth,  if  the  latter  be  left  on  the  model,  and 
holding  it  there  until  tlie  lead  congeals.  It  is  then  removed, 
and  the  whole  upper  surface  of  the  lead,  including  that  of 
the  mould  made  in  it  with  the  plaster-model,  covered  with 
a  thin  coating  of  whiting  in  the  manner  as  before  directed. 
After  this  has  become  perfectly  dry,  melted  block-tin,  at  a 
temperature  so  low  that  it  will  not  char,  or  even  discolor 
white  paper  when  dipped  and  held  in  it,  may  be  poured  on, 
until  the  cup  or  box  is  filled.  When  cold^  the  castings  may 
be  removed  from  the  iron  cup  or  box,  and  separated.  This 
done,  they  are  ready  for  use. 

When  a  metallic  model  and  counter-model  are  procured 
in  the  manner  as  last  described,  the  plaster  model  should 
not  be  varnished,  and  as  the  one  immersed  in  the  melted 
metal  is  generally  broken  in  removing  it,  a  duplicate,  var- 
nished as  before  directed,  should  be  obtained. 

When  it  is  necessary  to  have  brass  or  zinc  castings,  they 
are  made  in  sand,  as  first  described. 

Finally,  by  cutting  about  tliree-fourths  of  the  crowns  of 
the  teeth  from  the  plaster  model,  before  using  it  for  obtaining 
metallic  casts,  the  plate  may  be  fitted  more  easily  and  per- 
fectly to  the  teeth,  around  which  clasps  are  to  be  placed, 
than  can  be  done  when  they  remain  on  the  plaster  model, 
for,  in  the  former  case,  it  need  not  be  cut  to  fit  the  teeth 
until  it  has  been  swaged,  while  in  the  latter,  this  must  be 
done  first,  and,  consequently,  in  striking  it  up,  it  will  be 
drawn  to  a  greater  or  less  distance  from  them. 


CHAPTER      EIGHTH 


SWAGING  A  PLATE  AND  SOLDERING  CLASPS  TO  IT. 


A  MODEL  and  counter-model  having  been  obtained,  a  piece 
of  sheet-lead  is  adapted  to  the  alveolor  ridge,  and  the  dimen- 
sions of  the  plate  marked  upon  it  with  a  pointed  instrument. 
The  pattern  thus  marked  is  cut  out,  laid  upon  a  piece  of  gold 
plate  of  the  right  thickness,  and  its  size  and  shape  marked 
upon  it.  With  a  pair  of  strong  shears  or  snips,  (see  Fig. 
181,)  the  portion  of  plate  thus  marked  is  cut  out.     It  may 

Fia.  181. 


now  be  annealed,  and  then  partially  adjusted  and  fitted  to 
the  model  with  a  hammer  and  pair  of  plate-forceps  ;  again 
annealed,  and  afterwards  swaged  between  the  metallic  mod- 
el and  counter-model.  It  may  be  necessary  to  repeat  this 
operation  several  times,  annealing  the  plate  each  time,  be- 
fore a  perfect  adaptation  can  be  obtained.  This  done,  it 
should  be  filed  to  the  exact  size  required^  and  made  to  fit  the 
teeth  to  which  it  is  to  be  clasped  witli  perfect  accuracy. 

When  block-tin  or  lead  models  or  counter-models  are  used 
as  swages  for  the  plate,  any  portion  of  these  metals  which 
may  adhere  to  it,  should  be  removed  before  annealing,  as 
the  fusions  of  such  portions  upon  its  surface,  by  this  process, 
will  render  the  gold   brittle,  and,  in  some  degree,  destroy 


Y20  MANNER    OF   FITTING    AND    ATTACHING   CLASPS. 

its  ductility.  But  the  liability  of  the  tin  or  lead  to  adhere 
to  the  gold  may  be  measurably  prevented  by  oiling  the  plate 
before  it  is  struck  up. 

After  fitting  it  to  the  model,  it  is  applied  to  the  mouth _, 
for  the  purpose  of  ascertaining  if  the  impression  from  which 
the  model  was  procured  is  correct.  It  sometimes  happens 
that  this  is  imperfect ;  in  which  case,  a  new  one  will  have 
to  be  taken,  and  the  whole  process  of  procuring  plas- 
ter and  metallic  models  and  counter-models  again  gone 
through  with,  and  hence  the  propriety  of  the  precaution  of 
trying  it  in  the  mouth  before  the  clasps  and  teeth  are  at- 
tached. To  be  worn  with  comfort^  and  at  the  same  time  to 
subserve  any  valuable  purpose,  it  is  important  that  the  plate 
fit  perfectly  all  the  inequalities  of  the  parts  to  which  it  is 
applied.  When  an  unbroken  series  of  several  teeth  are  to 
be  sniiplied,  it  seldom  happens  that  much  diflficulty  is  ex- 
perienced in  fitting  the  plate,  but  when  the  loss  of  six  or 
eight  teethj  from  different  parts  of  the  dental  arch,  are  to  be 
replaced,  with  substitutes  attached  to  a  single  plate,  a  per- 
fect adaptation  to  the  various  inequalities  of  all  the  parts 
cannot  always  be  so  easily  secured. 

With  regard  to  the  width  of  the  plate,  and  the  peculiar 
form  and  shape  that  should  be  given  to  it  in  different  cases,, 
the  reader  will  be  able  to  form  a  pretty  correct  idea,  from 
tlie  illustrations  given  in  a  subsequent  chapter. 

FITTING    THE    CLASPS. 

The  plate  being  fitted,  it  is  applied  to  the  plaster  model, 
and  the  clasps  adapted  to  teeth — one  on  each  side  of  the 
mouth,  and  here  it  may  be  proper  to  repeat,  that  the  gold 
emi)loyed  for  this  purpose  should  be  about  one-third  or  one- 
half  thicker  than  the  plate, and  when  practicable,  nearly  as 
wide  as  the  crowns  of  the  teeth  are  long,  and  carefully  and 
accurately  fitted.  This  is  necessary  to  secure  to  the  piece 
the  greatest  possible  amount  of  stability,  and  to  prevent  the 
clasps  from   acting   as  retractors,  or   exercising   an   undue 


3       1 


MANNER   OF   FITTrNG   AND    ATTACHING   CLASPS.  721 

force  upon  the  teeth.  These  are  precautions  Avhich  should 
never  be  overlooked,  for,  if  the  clasps  act  unequally  upon  the 
teeth,  inflammation  of  the  alveolo-dental  membrane  Avill 
be  set  up^  followed  by  wasting  of  their  sockets,  and  ulti- 
mately loss  of  the  teeth. 

When  accurately  fitted,  they  maybe  attached  to  the  plate 
by  means  of  a  small  piece  of  wax,  or  cement  composed  of 
two  parts  wax,  and  one  of  resin,  previously  softened,  and 
applied  to  the  plate  and  to  the  inner  or  palatine  side  of  each 
clasp.  The  plate  and  clasps  thus  united,  are  carefully  re- 
moved from  the  plaster  model  and  laid  with  the  convex  side 
downward  on  a  piece  of  paper.  A  paste  or  batter  of  plaster 
of  paris  is  now  poured  on  the  upper  side  of  the  plate  and 
clasps  to  the  thickness  of  half  an  inch.  After  this  has  be- 
come dry,  the  piece  may  be  taken  from  the  paper,  turned 
over,  placed  on  charcoal  and  the  wax  softened  and  removed. 

This  is  the  usual  way  of  fitting  the  clasps  to  the  plate  and 
preparing  the  piece  for  soldering,  but  when  the  teeth  in  the 
mouth  to  which  these  fastenings  are  to  be  applied,  deviate 
from  a  vertical  position,  they  may  be  fitted  in  the  mouth, 
instead  of  to  the  teeth  on  the  plaster  model,  and  attached  to 
the  plate,  as  just  directed.  In  this  case  only  one  can  be  at- 
tached at  a  time,  and  alter  this  has  been  soldered,  it  should 
be  opened,  the  piece  placed  back  in  the  mouth,  and  the 
other  made  fast  to  the  plate.  The  greatest  care  too  will  be 
necessary  to  prevent  moving  or  altering  the  position  of  the 
clasp  in  taking  the  piece  from  the  mouth. 

Dr.  Fogle  adopts  a  different  method  for  securing  accurate 
adaptation  of  the  clasps.*  These  are  first  fitted  to  the  plas- 
ter model,  leaving  the  ends  straight.  A  narrow  strip  of 
plate,  about  five-eighths  of  an  inch  in  length,  is  employed  as 
the  temporary  fastening.  One  end  is  soldered  to  the  lin- 
gual surface  of  the  clasp,  the  plate  and  clasp  are  now  both 
placed  on  the  model,  and  the  other  end  fitted  and  soldered 
to  the  plate,  forming  a  sort  of  semicircle  or  bow.     Fig.  182 

*  Amer.  Jour,  and  Lib.  Dent.  Sci.,  voL  10,  p.  35, 


722 


MANNER    OF   FITTING   AND    ATTACHING   CLASPS. 


represents  the  plaster  model,  with  the  plate,  clasp  and  tem- 
porary fastenings.  In  Fig.  183  is  seen  the  plate,  clasps  and 
fastenings  without  the  model. 


Fro.  182. 


Fig.  183. 


The  clasps  are  now  only  adjusted  to  the  model,  and  how- 
ever accurately  they  may  have  been  adapted  to  this,  it  will 
be  found  on  applying  the  plate  to  the  mouth,  that  they  will 
not  fit  the  teeth  there,  but  after  properly  adjusting  them, 
the  temporary  fastenings  hold  them  in  the  exact  position 
in  which  they  are  placed  while  the  piece  is  removed.  This 
done,  it  may  be  placed  on  a  piece  of  paper  or  charcoal,  the 
concave  side  of  the  plate  upwards,  a  batter  of  plaster  ap- 
plied, and  the  other  steps  connected  with  the  process  of  per- 
manent soldering  gone  through  with. 

In  speaking  of  this  method  of  applying  clasps.  Dr.  Cush- 
man  says,*  ''In  very  difficult  cases  of  adjustment  as  where 
the  clasp-teeth  stand  leaning — where  3'ou  have  to  fasten  to 
the  second  or  third  molars,  it  will  be  found  still  more  ad- 
vantageous to  pursue  this  plan,  viz.  after  soldering  one  end 
of  the  strip  to  the  clasp,  and  having  bent  the  other  to  touch 
the  plate  when  on  the  model,  put  both  in  their  proper  place 
in  the  mouth  ;  then  with  a  sharp  pointed  instrument,  indi- 
cate the  point  where  the  bow  touches  the  plate,  place  them 
on  the  model  again,  adjust  the  end  of  the  bow  to  the  point 
marked,  confine  it  there  and  solder  fast." 


American  Journal  of  Dental  Science,  No.  1,  vol.  10. 


MANNER    OF   FITTING    AND    ATTACHING   CLASPS.  723 

Dr.  Cushman  says  further,  that  he  considers  this  method 
of  adjusting  clasps  so  valuahle  that  he  never  ventures  to  set 
clasps  permanently  in  the  simplest  case  by  the  model.* 

Mr.  Noble,  a  student  of  the  Baltimore  College  of  Dental 
Surgery  during  the  session  of  1849-'50,  suggests  another 
method  which  is  thus  described  by  Dr.  Austen  : 

''Let  the  clasp  bind  upon  the  tooth  only  with  sufficient 
jRrmness  to  keep  it  in  its  proper  place.  Then  mix  a  small 
quantity  of  plaster  from  a  lot  whicli,  by  previous  trial,  you 
find  requires  from  six  to  ten  minutes  to  set ;  put  it  upon  a 
piece  of  paper  or  sheet  lead  about  an  inch  square,  and  just 
before  it  begins  to  harden,  introduce  it  into  the  mouth  upon 
the  forefinger_,  pressing  it  into  gentle  contact  with  a  portion 
of  the  plate  and  about  one-half  of  the  clasp.  It  must  be 
held  there  for  from  three  to  six  minutes,  until  it  is  suffi- 
ciently hard  to  break  with  a  sharp  fracture  ;  this  point  jou 
can  determine  by  examining  the  plaster  left  in  your  bowl. 
The  plaster  must  then  be  withdrawn.  Sometimes  plate, 
clasp  and  plaster  will  be  brought  away  together  ;  or  the 
plaster  and  clasp  together,  leaving  the  plate  ;  or  the  plaster 
will  separate^  leaving  both  clasp  and  plate  in  the  mouth. 
Should  the  plaster  by  any  accident  break,  it  can  readily  be 
united  at  the  point  of  the  fracture,  without  in  the  least 
altering  its  shape — one  great  advantage  over  wax.  If  the 
plaster  adheres  to  the  plate  on  withdrawal  from  the  mouthy 
it  must  then  be  carefully  detached^  the  plate  replaced,  and 
the  same  process  repeated  for  the  second  clasp. 

"Several  precautions  are  necessary.  If  the  clasp  bind 
too  tightly  around  the  tooth,  its  ends  will,  when  removed, 
spring  together,  and  thus  it  will  not  exactly  fill  the  original 
impression  made  in  the  plaster.  If  the  part  of  the  clasp 
which  you  design  to  cover  with  plaster  be  so  regular  in  shape 
as  to  make  its  adjustment^  when  out  of  the  mouth,  uncertain, 
mark  it  with  a  file  or  by  a  small  point  of  solder  ;  this  will 
be  copied  in  the  plaster,  and  remove  all  doubt  as  to  its  defi- 

*  The  cuts  represented  in  Figs.  182  and  183,  are  from  a  model,  with  a  plate,  clasps 
and  temporary  fastenings  furnished  the  author  by  Dr.  Cushman. 


724  SOLDERIXG  CLASPS  TO  A  PLATE. 

iiite  position.  If  the  plaster  be  extended  over  some  part  of 
the  edge  of  the  plate,  it  will,  in  the  absence  of  any  marked 
irregularities  of  surface,  give  a  better  guide  for  its  re-adap- 
tation. Lastly,  if  the  plaster  cover  too  much  of  the  clasp- 
tooth,  it  will  be  more  liable  to  break  on  being  withdrawn. 

"Take  now  the  clasps,  place  them  each  in  their  separate 
impressions  in  the  pieces  of  plaster,  securing  them  if  neces- 
sary by  a  small  piece  of  softened  wax.  Place  one  end  of 
your  plate  in  its  corresponding  bed  in  one  of  the  plaster 
pieces.  If  proper  care  has  been  used,  both  clasp  and  plate 
will  fit  into  the  plaster  witli  unerring  accuracy,  and  of  course 
hold  the  precise  relation  as  when  in  tlie  mouth.  While  in 
this  position,  cover  tlie  clasp  and  the  part  of  the  plate  on  its 
surface  with  fresh  plaster  or  plaster  of  paris  and  sand — and 
when  this  has  hardened,  remove  the  first  plaster — just  as  in 
other  cases  you  would  remove  the  wax — preparatory  to 
soldering." 

The  author  has  not  had  any  experience  in  cither  of  the 
two  last  described  methods,,  as  he  has  always,  since  he  has 
been  acquainted  with  them,  been  able  to  secure  an  accurate 
adaptation  of  clasps  by  a  simpler  and  less  tedious  process. 
Cases  do  sometimes  occur,  however,  in  which  they  may  be 
resorted  to  with  advantage. 

SOLDERING  CLASPS  TO  A  PLATE. 

The  work  having  been  placed  upon  a  piece  of  charcoal, 
six  or  eight  inches  square,  is  made  fast  cither  with  clamps, 
iron  i)ins,  or  a  i)aste  of  plaster  of  paris.  The  edge  of  the 
plate  and  clasps  along  tlie  line  of  connection,  are  covered 
with  a  mixture  of  sub-borate  of  soda  (borax)  and  water,  of 
the  consistence  of  thin  cream,  prepared  by  grinding  the 
borax  in  clean  soft  water,  on  a  piece  of  glass  having  a  ground 
surface  of  from  four  to  six  inches  in  diameter,  or,  a  piece  of 
slate  of  the  same  size,  until  the  mixture  attains  the  above 
mentioned  consistence.  Thus  prepared^  it  is  applied  with  a 
camel' s-hair  pencil ;    after    which    several  small  pieces  of 


SOLDERING  CLASPS  TO  A  PLATE. 


725 


solder  made  from  recipe  No.  1  or  3,  are  placed  along  the 
line  of  connection  between  the  clasps  and  plate. 

The  piece  is  now  prepared  for  soldering,  and  it  is  hardly 
necessary  to  observe^  that  this  process  consists  in  uniting 
the  clasps  and  plate  by  melting  upon  each,  a  more  fusible 
metal,  (the  solder,)  which  serves,  by  chemical  attraction 
and  cohesive  force,  to  unite  or  bind  the  j)ieces  together. 
Thus,  gold  alloyed  with  silver  and  copper,  melts  more  easily 
than  the  first  named  metal,  and  having  an  affinity  for  it_, 
constitutes  a  projier  uniting  medium.  Tlie  surfaces,  how- 
ever, of  the  pieces  to  be  united,  should  be  bright  and  smooth, 
to  ensure  a  uniform  effect  of  the  solder  upon  them. 

A  number  of  ingenious  contrivances  have  been  invented 
for  applying  tiie  heat. 

Fig.  184. 


The  self-acting  blow-pipe  invented  by  Dr.  Jahial  Parmly, 
of  New  York,  is  one  of  the  best  and  most  convenient  appa- 
ratuses for  soldering  which  the  author  has  seen.  There  is 
also  a  small  furnace  accompanying  it,  which  is  very  useful 


FiQ.  184,  a  a  Side  of  case  ;  b  Top  of  case  thrown  back  ;  e  Front  of  case  united  by 
hinge  at  bottom,  and  shown  in  a  horizontal  position ;  d  d  An  oblong  fluid  vessel  for 
reception  of  alcohol ;  e  Vent  to  vessel  d  d,  for  introduction  of  fluid  ;  /  IJurncr  intro- 
duced in  groove  of  vessel  d  d;  g  g  Movable  extinguisher  to  burner  /,  and  not  for 
working  the  same,    h  Horizontal  plate  of  tin  for  sustaining  copper  globe  in  place ; 


720  SOLDERINa   CLASPS   TO   A   PLATE. 

for  licatiug  up  a  piece  preparatory  to  soldering,  also,  for 
melting  metal  for  casts,  and  even  gold.  The  apparatus  is 
arranged  in  a  small  portable  japanned  tin  case,  which  may 
be  opened  and  closed  at  pleasure,  as  may  be  seen  from  the 
representation  given  in  Fig.  184. 

Dr.  W.  H.  Elliot  has  added  a  very  ingenious  improve- 
ment to  the  selt-acting-blow-pipe.  We  copy  the  following 
description  and  drawing,  furnished  by  the  author : 

"This  ingenious  contrivance,  useful  as  it  may  be  to  the 
dental  artist_,  in  its  simple  form,  is  far  short  of  what  it  may 
be  rendered,  simply  by  supplying  it  with  a  larger  quantity 
of  the  supporting  principle  of  combustion. 

"The  fact,  that  the  centre  of  the  flame  of  the  self-acting- 
blow-pipe,  contains  no  oxygen,  it  is  well  known  to  every 
enlightened  dentist,  and  may  be  proven  by  placing  a  rod  of 
polished  metal  in  the  flame  for  a  few  seconds,  in  which  case  it 
will  be  seen  that  the  surface  of  that  portion  of  the  rod  occupy- 
ing the  centre  of  the  flame  does  not  unite  with  oxygen,  how- 
ever great  the  degree  of  heat  may  be ;  but  if  a  jet  of  atmos- 
pheric air  be  thrown  into  the  flame  upon  the  rod,  it  will  oxy- 
dize  as  readily  as  if  heated  by  any  other  means.   This  little  ex- 


t  Copper  globe;  j  j  An  oblong  vessel  for  the  reception  of  alcohol;  k  Vent  to 
vessel  j/,  for  feeding  same  with  fluid  ;  /  Burner  extending  from  fluid  in  jj;  m  Ex- 
tinguisher to  burner  I;  n  Sjphon  extending  from  fluid  in  vessel  jj,  to  near  the  bot- 
tom of  globe  i  ;  o  Stop-cock  to  syphon  ;  pBlovv-pipe  from  top  of  globe  i  ;  q  Asmall 
copper  trough  for  retaining  condensed  vapor  that  escapes  from  blow-pipe. 

The  manner  of  working  Dr.  Parmly's  self-acting-blow-pipe  is  very  simple.  The 
two  vessels  d  d  and  j  j,  being  filled  with  alcohol,  the  stop-cock  o  is  closed ;  the 
mouth  is  then  applied  to  the  end  of  the  blow-pipe  j)  and  the  atmospheric  air  ex- 
hausted from  the  globe;  when  the  stop-cock  is  turned,  the  alcohol  in  vessel^  will 
rush  through  the  syphon  and  fill  the  globe,  should  the  air  continue  to  bo  exhausted. 
For  all  practical  purposes,  the  globe  should  be  only  partially  filled,  and  the  stop- 
cock turned  so  as  to  close  the  syphon.  The  burner  /  should  be  ignited,  and  in 
about  five  minutes,  alcoholic  vapor  will  be  seen  to  rush  out  from  blow-pipe^,  when 
the  burner  I  should  be  ignited.  The  volume  of  flame  can  be  governed  by  the  ex- 
tinguishers g  and  m. 

When  the  lamp  is  used  for  melting  metal  for  castings,  the  metal  should  be  placed 
in  an  iron  ladle,  .and  this  latter  in  the  furnace  pi-eviously  filled  with  charcoal,  and 
placed  in  a  proper  position,  as  represented  in  Fig.  181,  for  the  flame  of  the  lamp  to 
be  thrown  into  it  against  the  coal.  When  it  is  desired  to  melt  gold,  a  crucible 
should  be  used  instead  of  the  iron  ladle. 


SOLDERING. 


727 


periment,  proves  not  only  the  want  of  oxygen  in  the  flame,' 
but  it  leads  to  a  very  important  conclusion,  that  without 


Fig.  185. 


Fio.  185.  a  a  Air-pipe  leading  from  the  bellows  to  the  lamp ;  b  Vapor-pipe ; 
e  c  c  A  round  bellows,  10  inches  in  diameter  ;  d  A  rod  attached  to  the  upper  mova- 
ble head  of  the  bellows,  and  passing  through  cross-piece  c,  which  serves  to  keep 
the  head  in  a  horizontal  position ;/ A  rod  attached  in  a  similar  manner  to  the 
lower  movable  head  of  the  bellows  and  passing  down  through  the  tabic;  </  A  stir- 
rup attached  at  the  upper  end  to  shaft  h  h;  i  i  support  for  shaft  h  h,  by  means  Of 
an  arm  projecting  backwards  from  shaft  h  h,  and  attached  to  the  lower  end  of  rod 
/,  the  force  is  communicated  from  the  foot  of  the  artist  to  the  bellows. 


728  SOLDERING. 

oxygen,  the  burning  of  the  vapor  must  be  gradual  and  im- 
perfect. In  consideration  of  this  fact,  the  writer  was  led  to 
make  another  experiment,  that  of  producing  a  more  perfect 
combustion,  by  throwing  into  the  flame  one  of  its  sup- 
porters. This  may  be  done  in  several  ways,  but  the  sim- 
plest and  most  convenient  is  atmospheric  air,  thrown  in  by 
means  of  a  bellows.  For  this  purpose,  the  exhalations  of 
the  lungs  will  not  do  as  well,  inasmuch  as  they  not  only 
contain  less  oxygen,  but  also  contain  a  large  portion  of 
carbonic  acid,  which  neutralizes  so  much  of  the  remaining 
oxygen  as  to  render  it  unfit  for  the  support  of  combustion. 

"The  air-pipe  must  pass  along  by  the  vapor-pipe,  and 
discharge  about  an  inch  and  a  half  beyond  it  in  the  very 
centre  of  the  flame,  and  in  precisely  the  same  direction. 
The  calibre  of  the  air-pipe  at  its  apex,  must  be  equal  to  that 
of  tlie  vapor-pipe  ;  it  must  be  made  as  small  as  possible 
without  being  enlarged  at  the  end,  as  any  enlargement 
there  would  derange  the  vajDor  flame  ;  it  must  also  be  con- 
structed of  platina,  as  that  is  the  only  metal  that  will  resist 
for  any  length  of  time,  the  heat  of  the  burning  vapor. 

"The  air-pipe  appears  to  throw  out  a  pale  blue  flame, 
about  two  inches  in  length,  small  and  pointed.  At  the 
very  point  of  this  flame,  the  oxygen  being  all  consumed, 
the  greatest  amount  of  heat  is  produced,  and  fusion  of  the 
solder  takes  place  without  oxydation  ;  but  within  the  blue 
flame,  or  far  from  it,  where  oxygen  preponderates,  oxyda- 
tion of  the  solder  goes  on  rapidly. 

"The  necessary  weight  to  be  given  to  the  bellows^  can 
only  be  determined  by  experiment,  as  it  depends  entirely 
upon  the  force  of  the  rest  of  the  instrument. 

"The  extra  heat  gained  by  the  introduction  of  the  air- 
pipe^  is  nearly  all  concentrated  at  the  apex  of  the  blue  flame, 
which  may  be  brought  to  bear  upon  the  point,  to  be  sol- 
dered, while  the  vapor  flame  keeps  tlie  whole  work  in  a 
.state  of  readiness." 

Dr.  R.  Somerby  has  invented  a  furnace  and  blow-pipe, 
which  every  dentist  would  find  exceedingly  convenient  and 


SOLDERING. 


729 


useful  in  his  mechanical  workshop  ;  especially  as  it  sub- 
serves a  number  of  very  valuable  purposes. 


Fig.  186. 


Fio.  186.  a  A  perspective  of  Dr.  R.  Somerby'g  concentrated  blow-pipe  and  fur- 
nace; b  The  lamp;  c  Lamp  stand ;  d  Blow-pipe;  e  Cock,  to  cut  oflF  the  air  from 
blow-pipe ;  /  Slide  to  raise  or  lower  the  lamp;  g  Top  of  table ;  h  Cover  to  the  fur- 

47 


730 


SOLDERING. 


The  process  of  soldering  is  rendered  more  easy  by  this 
blow-pipe  than  by  the  usual  method,  and  is,  therefore,  to 
those  of  the  profession  who  are  stationary,  and  occupy 
themselves  much  in  mechanical  dentistry,  invaluable.  The 
furnace  attached  to  it  answers  all  the  purposes  of  melting 
gold,  solder,  and  the  metal  employed  for  casts.  The  frame 
is  made  of  iron,  and  so  constructed  and  arranged  as  to  oc- 
cupy but  little  room.  The  smoke  from  the  furnace  is  car- 
ried off  by  means  of  a  stove-pipe — the  lower  piece  of  which, 
being  so  arranged  that  it  may  be  raised  and  lowered  at  plea- 
sure, and  of  a  conical  shape,  so  as  to  cover  the  whole  of  the 
oj3ening  into  the  furnace.  When  the  furnace  is  used,  this 
is  raised,  and  let  down  when  it  is  not  needed.  As  use- 
ful as  is  this  apparatus  to  the  dentist,  it  is  equally  valua- 
ble to  the  chemist  and  mineralogist,  or  for  any  purjjose 
requiring  a  steady  blast  from  the  blow-pipe  or  heat  from  a 
furnace. 

The  most  common  method,  however,  of  soldering,  is  with 
an  ordinary  spirit  or  oil  lamp  and  simple  blow-pipe,  but  by 
either,  considerable  practice  is  necessary  to  accomplish  the 
process  with  ease,  and  the  perfection  of  finish,  necessary  to 
be  put  on  a  piece  of  dental  mechanism,  depends,  in  a  great 

measure,  upon  the  manner 
in  which  this  part  of  the 
operation  is  performed. 

Tlie  lamp  should  hold  at 
least  a  pint,  and  have  a 
spout  three  or  four  inches 
long  and  about  three-fourths 
of  an  inch  in  diameter.  The 
appearance  of  such  a  lamp 
is  exhibited  in  Fig.  187. 
The  blow-pipe  should  be  from  fifteen  to  eighteen  inches 

race  ;  i  The  furnace  ;  J  The  pan  to  receive  the  ashes  fiom  the  furnace;  i  The  valve 
at  bottom  of  the  furnace;  Z  The  pipe  leading  from  the  bellows  to  the  furnace; 
m  The  stop-cock  to  cut  off  the  wind  from  furnace;  n  The  main  pipe  leading  from 
the  bellows  to  the  furnace  and  blow-pipe;  o  The  bellows;  p  Weight  on  the  top  of 
bellows ;  r  The  treadle ;  s  The  table  legs. 


Fig.  187. 


SOLDERING.  731 

long,  have  a  tolerably  large  orifice,  and  the  end  to  be  taken 
into  the  mouth  should  either  be  gilded  or  plated  with 
silver.     It  is  curved  in  the  manner  represented  in  Fig.  188. 

Fig.  188. 


When  a  spirit  lamp  is  used,  and  the  author  thinks  it 
preferable  to  oil,  the  wick  should  be  large  enough  to  fill  the 
spout,  to  prevent  the  flame  from  extending  back  into  the 
body  of  the  lamp  and  causing  an  explosion,  an  accident 
very  apt  to  happen  when  this  precaution  is  not  observed. 
The  coal  containing  the  work  to  be  soldered,  may  be  either 
held  in  the  hand,  or  in  a  copper  or  sheet  iron  cup  having 
a  wooden  handle.  The  flame  of  the  lamp  is  first  thrown 
upon  the  plaster,  and  kept  there  until  its  temperature  is 
raised  to  a  red  heat,  then  directed  upon  the  part  to  be  sol- 
dered until  it  is  heated  to  nearly  a  white  heat,  when  it  is 
brought  to  a  smaller  focus,  and  kept  steadily  upon  the  part 
where  it  is  desired  tliat  the  solder  should  take  effect. 
When  this  melts  and  spreads  itself  along  the  line  of  connec- 
tion between  the  clasp  and  plate,  the  point  of  flame  is  di- 
rected upon  any  other  part  or  parts  to  be  soldered. 

If  the  flame  be  continued  too  long,  there  will  be  danger 
of  melting  the  plate,  and  by  an  improper  application  of 
heat,  the  solder  may  be  partially  melted  and  run  together, 
forming  small  globules.  But  a  little  practice  will  enable 
the  student  to  determine  tlie  quantity  of  heat  required  and 
the  length  of  time  it  sliould  be  continued.  If  the  solder, 
after  it  has  melted,  flows  in  a  wrong  direction,  the  flame 
of  the  lamp  is  immediately  concentrated  upon  the  point 
where  it  should  take  effect,  when  it  will  at  once  be  brought 
to  it. 

The    plaster,  after    the    piece  has  cooled  sufficiently,  is 


732 


SOLDERING. 


removed,  and  the  piece  put  in  a  mixture  of  equal  parts  of 
sulphuric  acid  and  water^  where  it  should  remain  long 
enough  for  the  horax,  which  will  be  found  adhering  to  the 
plate  to  be  dissolved,  and  for  cleansing  the  gold.  But  a 
few  minutes,  however,  will  be  required  for  this. 

The  crystallized  borax  being  removed,  the  solder,  if 
rough,  is  filed  smooth  and  rubbed  with  scotch-stone,  before 
arranging  and  adjusting  the  teeth. 


CHAPTER      NINTH. 


MANNER  OF  OBTAINING  AN  ANTAGONIZING  MODEL. 


If  the  model  is  required  for  antagonizing  only  part  of  an 
upper  denture — there  being  natural  teeth  in  the  lower  jaw 
that  antagonize  with  those  which  remain  in  the  upper — it 
may  be  obtained  in  the  following  manner. 


Fig.  189. 


After  having  made  the  surface  of  the  solder,  uniting  the 
plate  and  clasps,  smooth  with  suitable  scorpers,  (scrapers,) 
and  files,  the  plate  should  bo  placed  in  the  mouth,  and,  if  a 
series  of  artificial  teeth  are  to  be  attached  to  it,  a  rim  of 
softened  bees-wax  is  placed  on  it ;  the  patient  is  then  re- 
quested to  close  his  jaws  naturally,  imbedding  the  teeth  of 
the  lower  jaw  in  it.  While  the  mouth  is  thus  closed,  the 
wax  on  the  outside  of  the  teeth  and  alveolar  ridge  is  pressed 
closely  against  them.  This  done,  the  patient  may  open  his 
mouth,  then  the  plate  and  wax  impression  are  carefully  re- 
moved and  placed  on  a  piece  of  paper,  with  the  plate  up- 
wards.    The  upper  side  of  the  plate  is  now  smeared  with 


734        MANNER   OF   OBTAINING   AN   ANTAGONIZING    MODEL. 

olive  oil,  and  filled  with  a  thin  paste  made  of  plaster  of 
paris.  As  soon  as  the  plaster  has  become  sufficiently  thick, 
it  may  be  applied  until  it  is  raised  half  an  inch  above  the 
plate,  and  extended  back  of  it  on  the  paper  an  inch  and 
a  half  or  two  inches.  As  soon  as  the  plaster  has  set,  it  may 
be  neatly  trimmed  around  the  edges^  and  on  the  lower  sur- 
face behind  the  plate  and  wax,  a  deep  crucial  groove  is  cut^ 
or  several  conical  depressions,  three-eighths  of  an  inch  deep, 
excavated,  to  serve  as  moulds  for  the  formation  of  corres- 
ponding ridges  or  protuberances  on  the  model  with  which 
this  is  to  antagonize.  The  grooves  or  depressions  thus 
formed,  as  well  as  the  impression  made  in  the  wax  by  the 
teeth  of  the  lower  jaw,  after  the  plaster  has  become  dry,  is 
oiled,  and  filled  with  a  thin  paste  of  plaster,  and  as  soon  as 
the  latter  has  acquired  suflScient  consistence,  it  is  poured  on 
until  this  side  is  raised  to  a  thickness  equal  to  that  of  the 
side  first  filled. 

By  this  simple  contrivance,  an  exact  representation  of  the 
manner  in  which  the  jaws  meet,  is  obtained,  and  the  most 
accurate  and  convenient  antagonizing  model  procured  that 
can  possibly  be  made,  and  provided  with  this,  the  dentist  is 
prepared  to  select,  arrange  and  antagonize  the  teeth. 

After  the  plaster  has  set,  it  may  be  trimmed  as  before 
directed.  When  it  has  become  perfectly  dry,  the  two  pieces 
may  be  separated,  and  the  wax  and  plate  carefully  removed. 
The  model  is  now  varnished,  and  when  put  together  will 
present  the  appearance  exhibited  in  Fig.  189. 

When  the  model  is  designed  for  antagonizing  a  complete 
upper  denture,  a  piece  of  wood,  equal  in  width  to  the  length 
required  for  tlie  artificial  teeth  may  be  passed  through  the 
wax  after  it  has  been  arranged  to  the  plate  at  a  point  cor- 
responding with,  and  in  the  direction  of,  the  median  line. 
The  plate  may  then  be  placed  in  the  mouth,  and  the  patient 
directed  to  close  his  jaw  naturally,  until  the  teeth  of  the 
lower  come  in  contact  with  the  wood.  The  mouth  may  now 
be  opened,  and  the  plate  and  wax  impression  of  the  lower  teeth 
removed.     This  done,  the  plaster  model  may  be  made  in  the 


MANNER   OF   OBTAINING   AN   ANTAGONIZING    MODEL. 


735 


manner  as  before  directed,   and,  when  completed,  it  will 
present  the  appearance  represented  in  Fig.  190. 


Fio.  190. 


An  antagonizing  model  may  also  be  made  by  adjusting  a 
rim  of  wax  to  the  plate  corresponding  in  width  to  the  length 
proposed  for  the  artificial  teeth,  and  cut  away  until  all  the 
teeth  in  the  lower  jaw  touch  it  at  the  same  instant.  This 
done,  the  plaster  is  aj)plied  as  before  directed. 

Fio.  101. 


In  making  an  antagonizing  model  for  a  complete  denture, 
or  double  set  of  artificial  teeth,  the  following  is  the  usual 
method  of  procedure.  After  having  fitted  accurately  both 
plates,  a  rim  of  soft  bees-wax  is  placed  between  their  con- 


736        MANNER   OF   OBTAINING   AN   ANTAGONIZING    MODEL. 

vex  surfaces^  of  about  an  inch  and  a  quarter  in  widtli.  A 
piece  of  soft  wood,  exactly  corresponding  in  width,  to  the 
length  it  is  designed  that  both  the  upper  and  lower  central 
incisors  should  have,  is  passed  through  the  wax  between  the 
plates,  at  the  median  line.  The  whole  is  now  placed 
in  the  mouth  of  the  patient,  and  each  plate  accurately  ad- 
justed to  the  alveolar  border.  The  patient  is  now  directed 
to  close  his  jaw  naturally  until  the  plates  are  brought  in 
contact  with  the  edges  of  the  interposed  piece  of  wood. 
This  done,  the  whole  may  be  removed  from  the  mouth,  the 
plates  oiled,  and  a  plaster  model  obtained  in  the  manner  as 
before  described.     See  Fig.  191. 

Another  method  of  making  an  antagonizing  model  con- 
sists in  placing  a  rim  of  wax  on  each  plate,  each  corres- 
ponding in  width  to  the  length  respectively  designed  for  the 
teeth.  The  two  plates  are  put  in  the  mouth,  the  lower  first, 
and  then  the  upper.  The  jaws  are  now  carefully  closed ; 
and  if  the  rims  of  wax  touch  at  any  one  point  sooner  than  an- 
other, the  plates  are  removed,  the  wax  trimmed,  and  this 
operation  repeated  until  the  two  rims  of  wax  meet  all  the 
way  round,  at  the  same  instant,  and  are  exactly  of  the  right 


width.     This  done,  the  wax  is  trimmed  on  the  outside,  until 
the  proper  contour  is  given  to  the  cheeks  and  lips.     The 


MANNER    OF   OBTAINING   AN   ANTAGONIZING   MODEL. 


131 


median  line  is  now  marked,  the  plates  removed  from  the 
mouth,  and  the  plaster  antagonizing  model  made. 

Dr.  Thomas  W.  Evans  has  invented  a  very  simple  instru- 
ment, by  means  of  which  the  extension  of  the  plaster  back 
of  the  plates  and  wax  is  rendered  unnecessary.  With 
an  antagonizing  model  made  in  this  instrument,  the  bite 
may  be  changed  at  pleasure,  by  increasing  or  diminishing 
the  length  of  the  rod  between  the  frame  work  supporting 
the  upper  and  lower  j)arts  of  the  model.  The  instrument  is 
represented  in  Fig.  192. 

Fig.  193. 


In  making  an  antagonizing  model  with  this  instrument, 
the  following  is  the  method  of  procedure  j)ursued  by  the 
author.  Supposing  the  model  to  be  for  an  upper  set  of  teeth, 
a  rim  of  wax  is  2)laced  upon  the  plate,  and  all  the  prepara- 
tory steps  gone  through,  as  already  described.  The  con- 
cave part  of  the  plate  is  oiled  and  filled  with  a  batter  of 
plaster  ;  the  upper  part  of  the  frame  work  of  the  instrument 
A  A  is  placed  on  it^  more  plaster  is  then  added  until  this  is 
completely  covered.  When  the  plaster  has  set,  it  is  turned 
over,  so  that  the  wax  impression  of  tlie  lower  teeth  and  jaw 
is  upwards  ;  this  is  then  filled  with  a  batter  of  plaster,  and 
the  lower  part  of  the  frame-work  of  the  instrument  turning 
on  the  hinge-rod  C  is  placed  on  it,  the  screw  being  loosenec 


738        MANNER   OF   OBTAINING   AN   ANTAGONIZING    MODEL. 


SO  that  the  rod  may  not  keep  the  jaws  too  wide  apart.  More 
plaster  is  added  until  the  lower  jaw  of  the  instrument  B  B 
is  imbedded  in  it.  This  done,  the  rod  is  moved  until  it 
presses  against  it  behind  the  plaster,  when  it  is  made  fast 
with  the  screw. 

After  the  plaster  has  become  hard,  the  jaws  of  the  instru- 
ment are  opened,  the  wax  warmed  and  removed.  The  model 
will  now  present  the  appearance  represented  in  Fig.  193. 
If  it  is  found  that  longer  or  shorter  teeth  are  required  than 
is  indicated  by  the  model,  the  width  of  the  bite  may  be  in- 
creased or  diminished,  by  increasing  the  length  of  the  rod 
between  the  two  jaws  of  the  instrument. 


CHAPTER     TENTH. 

ARRANGING,  FITTING,  ANTAGONIZING,  AND  ATTACHING 
PORCELAIN  TEETH  TO  A  PLATE-FINISHING  AND  AP- 
PLYING THE  PIECE. 

Where  a  vacuity,  requiring  only  one  or  even  five  or  six 
teeth,  is  to  be  filled,  it  is  important  that  the  artificial  cor- 
respond in  shade  and  color  with  the  natural  organs,  for  in 
proportion  as  they  are  whiter  or  darker,  will  the  contrast 
be  striking.  But  of  the  two,  it  is  better  that  they  should 
be  a  little  darker  than  any  whiter.  Their  outer  configura- 
tion should  resemble,  too,  the  shape  of  those  which  have 
been  lost. 

As  they  are  selected,  they  may  be  arranged  on  the  plate, 
and  retained  in  place  by  a  piece  of  wax  placed  on  it  behind 
them.  If  they  do  not  fit  closely  to  the  plate  and  gums,  they 
may  be  ground  on  an  emery  or  corundum  wheel  or  small 
grindstone,  until  they  do,  and  be  so  arranged  as  to  meet  the 
teeth  with  which  they  are  intended  to  antagonize,  at  the 
same  instant  the  natural  teeth,  that  have  antagonists^  come 
together.  The  antagonizing  models  Avill  enable  the  dentist 
to  do  this  with  the  most  perfect  accuracy. 

In  arranging  an  entire  set  for  the  upper,  or  for  both  jaws, 
the  teeth  are  so  adjusted  that  the  inner  or  palatine  tubercles 
of  the  upper  strike  the  depressions  in  the  lower,  before  the 
outer  tubercles  come  together.  This  precaution  is  necessary, 
in  antagonizing  single  as  well  as  block  teeth.  If  the  outer 
tubercles  strike  first,  the  pressure  there  will  spring  and 
loosen  the  plate.  A  small  space,  too,  should  be  left  between 
the  last  tooth  of  the  upper  and  of  the  lower  jaw. 


740 


MANNER   OF   ARRANGING   PORCELAIN   TEETH. 


It  being  necessary  to  cut  away  a  considerable  portion  of  a 
tooth  in  order  to  make  it  fit  accurately  to  the  plate,  a  number 
of  corundum  wheels,  or  small  grindstones^  varying  from 
three-fourths  of  an  inch  to  six  or  seven  inches  in  diameter  are 
required,  and  these  may  be  revolved  in  a  small  foot-lathe,  like 
the  one  represented  in  Fig.  194.  Connected  with  the  one  here 
shown  is  a  cabinet  work-table,  so  arranged  as  to  furnish  every 
convenience  required  by  the  dentist.  It  is  also  so  contrived 
that  it  may  be  closed  at  pleasure,  concealing  the  implements 
and  appliances  belonging  to  it,  presenting  the  appearance  of 
a  beautiful  piece  of  furniture.     Fig.  194  represents  it  with 


Fig.    194. 


Fig.   195. 


the  upper  and  lower  parts  open,  exposing  tlie  mandrel  on 
which  grinding  wheels  and  finishing  brushes  may  be  placed, 
according  as  the  one  or  other  may  be  needed,  as  also  the 
wheel  and  treadle  by  which  they  are  made  to  revolve,  and 
several  small  drawers.  In  Fig.  195  is  shown  the  work- 
table,  partially  drawn  out,  and  the  lower  part  closed. 
The  teeth  being  thus  arranged  and  adjusted,  a  gold  plate, 


JIANNER    OF   ARRANGING   PORCELAIN   TEETH. 


741 


large  enough  to  cover  the  posterior  surface  of  each,  is  fitted 
to  them  in  the  following  manner  :  Each  tooth  has  securely 
fixed  in  the  back  part  of  it  two  platina  rivets,  for  the  pur- 
pose of  connecting  it  to  the  backing.  Each  backing,  there- 
fore, should  have  two  holes  punched  through  it,  by  means 
of  a  pair  of  dentists'  punch  forceps,  like  those  represented 
in  Fig.  196,  large  enough  to  admit  the  rivets  of  the  teeth, 
and  of  the  same  distance  from  each  other.     After  having 

Fio.  196' 


punched  one  hole,  the  point  of  the  other  may  be  marked  by 
placing  the  backing  against  the  tooth,  with  the  rivet  nearest 
the  coronal  extremity  in  the  hole  ;  then,  by  moving  the 
strip  of  gold  plate  two  or  three  times  to  the  right  and  left, 
a  mark  will  be  left  upon  it,  indicating  the  distance  the 
rivets  are  from  each  other.  The  holes  on  the  back  part  of 
the  plate  should  be  slightly  enlarged,  and  after  placing  it 
on  the  tooth,  it  is  made  fast,  by  very  slightly  battering,  with 
a  light  hammer,  the  ends  of  the  platina  rivets,  or  bending 
them  in  opposite  directions.  If  the  ends  of  the  platina 
rivets  are  struck  up  so  as  completely  to  fill  the  holes  in 
the  backings,  it  will  prevent  the  solder  from  flowing  in  and 
uniting  the  two  as  firmly  as  it  should  do.  The  backings 
may  be  slightly  hollowed  before  they  are  put  on.  By  doing 
this  they  each  will  fit  up  closely  to  every  part  of  the  back 
of  each  tooth,  and  the  plate  employed  for  this  purpose 
should  be  slightly  thicker  than  that  on  which  the  teeth  are 
mounted. 

After  the  backings  have  been  made  fast  to  the  teeth,  they 


742  MANNER   OF   ARRANGING    PORCELAIN  TEETH. 

are  accurately  fitted  to  the  plate,  and  retained  by  tlie  wax 
behind  them. 

The  plate,  with  the  teeth  and  wax  on  it,  after  the  back- 
ings have  been  put  on,  are  carefully  removed  from  the  plaster 
model,  and  placed  on  a  large  piece  of  charcoal,  using  the 
precaution  not  to  disturb  or  disarrange  the  teeth.  A  paste, 
made  with  plaster  of  paris,  asbestos,  and  water,  of  the  thick- 
ness of  thin  batter,  is  next  poured  around  them,  until  the 
outer  surface  and  coronal  extremities  are  covered  to  the 
thickness  of  half  an  inch.  When  this  has  become  hard, 
the  wax  may  be  removed  from  behind  the  teeth. 

If  it*  should  be  found,  on  the  removal  of  the  wax,  that 
the  backings  do  not  fit  accurately  to  the  plate,  the  apertures 
may  be  filled  with  gold  ibil  or  small  pieces  of  gold  plate. 
This  done,  borax,  triturated  in  water,  until  of  the  consist- 
ence of  cream,  is  applied  with  a  camel' s-hair  pencil  to  all 
the  parts  where  it  is  wished  that  the  solder  should  take 
effect,  not  omitting  the  platina  rivets  that  pass  through  the 
backings,  as  these  cannot  be  made  too  secure. 

Mr.  Andrew  Wilson  adopts  a  different  method  in  backing 
mineral  teeth.  He  says,  "After  having  partially  fitted  the 
tooth  to  the  plate^  take  a  piece  of  thick  platina  foil,  as  thick 
as  can  be  used  conveniently,  and  pressing  it  against  the 
back  of  the  tooth,  perforate  it  where  it  is  marked  by  the 
pins  ;  then  cut  it  into  the  shape  of  the  back  as  wished  to 
be,  and  press  it  as  closely  as  possible  to  the  back  of  the 
tooth . 

"It  will  now  be  requisite  to  apply  a  little  borax  to  the 
platina  pins  which  come  through  the  back,  and  placing  the 
tooth  with  its  face  downwards  upon  a  thin  piece  of  pumice, 
covered  with  dry  plaster  of  paris,  put  several  pieces  of  gold 
(according  to  the  thickness  required)  upon  the  platina  back, 
slowly  heat  it,  gradually  raising  the  heat  till  it  is  considered 
safe  to  melt  the  gold  with  the  blow-pipe,  when,  upon  con- 
tinuing the  blast,  the  gold  will  rapidly  flow  over  the  whole 
platina  surface,  incorporating  so  accurately  with  the  pins  in 
the  tootlij  that  I  have  never  seen  a  case  withdrawn  wlien 


MANNER   OF   ARRANGING  PORCELAIN  TEETH. 


T43 


the  tootli  lias  been  broken,  during  the  whole  time  it  has 
been  in  use  here,*  (nearly  eight  years,)  they  always  remain- 
ing firmly  fixed  in  the  backing  upon  the  plate. 

"After  the  backing  has  been  run,  and  the  tooth  allowed 
to  cool  slowly,  it  is  filed  to  the  requisite  thickness  and 
shape,  when,  being  closely  fitted  to  the  base,  it  is  finally  sol- 
dered to  the  plate,"  in  the  manner  as  we  have  already  de- 
scribed. In  arranging  the  teeth  on  the  plate  for  soldering, 
Mr.  Wilson  says,  he  uses  a  mixture  of  equal  parts  of  white 
sand   and   plaster^  placing  a  thin  strip  of  platina  on  the 

Fia.  197. 


outside  of  the  teeth,  with  a  "layer  of  the  above  mixture  on 
both  sides  of  it  so  that  should  the  plaster  crack  in  soldering, 
although  it  is  less  liable  to  do  so  than  plaster  alone,  the 
platina  keeps  the  teeth  from  shifting  their  places.     The 

*  Edinburgh,  Scotland. 


T44  MANNER   OF   ARRANGING  PORCELAIN   TEETH. 

wliole  time  occupied  in  heating  and  backing  a  tootli  is  about 
half  an  hour,  and  when  several  are  doing  at  once,  a  little 
longer." 

Instead  of  using  the  strip  of  platina  plate  to  prevent  the 
teeth  from  becoming  displaced,  in  case  the  plaster  cracks, 
the  author  has  used  thin  sheet  iron. 

When  the  surface  of  the  plate  covering  the  alveolar  ridge 
is  very  uneven^  greater  accuracy  may,  perhaps_,  be  secured 
in  fitting  the  backings  to  it,  by  placing  the  plate  on  a  piece 
of  charcoal,  after  the  teeth  have  been  arranged,  ground  up, 
antagonized  and  fixed  to  it  with  wax,  then  cover  their 
outer  or  labial  surfaces  and  coronal  extremities  with  a 
paste  or  batter  of  plaster  and  asbestos,  to  the  thickness  of 
half  an  inch.  After  this  has  become  dry,  the  wax  may  be 
warmed  and  removed,  and  the  teeth  taken  ofP,  one  by  one 
backed,  and  then  replaced.  In  this  way  the  backings  may 
be  adjusted,  and  made  to  fit  with  the  greatest  exactness.  A 
piece  thus  prepared  and  fixed  on  charcoal,  for  soldering,  is 
shown  in  Fig.  197. 

After  applying  the  borax,  a  number  of  small  pieces  of 
solder,  made  from  recipe  No.  1  or  2,  are  applied  immediate- 
ly on  the  line  of  connection  between  each  tooth  and  the 
plate,  and  one  over  each  rivet. 

In  soldering  the  teeth  to  the  plate,  the  heat  is  applied  by 
means  af  a  large  flaring  lamp,  until  the  whole  mass  becomes 
red,  and  then  by  one  of  about  half  an  inch  in  diameter, 
thrown  immediately  on  the  line  of  connection  between  the 
backing  of  a  single  tooth  and  the  plate  ;  as  soon  as  the  solder 
flows  freely  here  and  over  each  rivet,  the  flame  passed  to  the 
adjoining  tooth,  and  so   on  until    the   process  is  completed. 

When  the  solder  runs  in  a  wrong  direction,  the  heat,  as 
before  stated,  should  be  increased  at  the  point  where  it  is 
wished  that  it  should  take  eff'ect. 


MANNER   OF   FINISHING  AND   APPLYING  A  PLATE.  "745 


FINISHING    AND  APPLYING  A   PLATE  MOUNTED  WITH   PORCELAIN 

TEETH. 

After  the  process  of  soldering  is  completed,  the  plaster,  as 
soon  as  the  piece  has  cooled  sufficiently,  is  carefully  removed 
from  the  teeth,  and  the  piece  placed  in  a  glass  or  porce- 
lain vessel  containing  a  mixture  of  equal  parts  of  sulphuric 
acid  and  water.  As  soon  as  the  borax,  which,  by  the  pro- 
cess of  soldering,  has  lost  its  water  of  crystallization  and 
assumed  a  glassy  hardness,  is  decomposed,  it  is  removed. 
This  process  is  termed  by  jewelers,  pickling,  and  requires 
from  ten  minutes  to  half  an  hour  for  its  completion,  accord- 
ing to  the  strength  of  the  acid  and  the  quantity  of  vitrified 
borax  on  the  plate.  After  this  is  decomposed,  the  acid  is 
washed  from  the  piece,  and  any  rough  portions  of  solder  on 
the  plate  or  backings  carefully  removed  by  means  of  suita- 
ble scrapers. 

In  removing  the  roughness  which  may  have  been  occa- 
sioned by  the  imperfect  fusion  and  unevenness  of  any  of  the 
pieces  of  solder,  or  from  its  flowing  in  a  wrong  direction,  care 
must  be  taken  not  to  cut  away  too  much  of  the  plate.  Af- 
ter the  work  has  been  made  as  smooth  as  possible  with  scra- 
pers, so  constructed  as  to  be  readily  apj^lied  and  made  to  act 
upon  every  part  of  the  surface  of  the  plate,  backings  of  the 
teeth  and  clasps,  it  may  be  rubbed  with  pieces  of  scotch 
stone  and  water  until  every  scratch  is  removed. 

The  piece  is  now  placed  in  a  porcelain  vessel  containing 
the  following  mixture : 

Pul.  nitrate  of  potass,  §ij. 

Muriate  of  soda. 

Alum, 

Water, 

After  boiling  for  half  an  hour  in  this,    to  decompose  the 
the  copper  in  the   surface  of  the   solder,  it  is   boiled  a  few 
48 


746         MANNER   OF    FINISHING   AND   APPLYING   A   PLATE. 

minutes  in  four  ounces  of  water,  and  one  ounce  of  sub.  carb. 
soda,  for  the  purpose  of  neutralizing  the  acid  formed  by  the 
first  mixture,  and  then  washed  with  a  brush  in  pure  water. 
The  copper  being  removed  from  the  surface  of  the  plate, 
the  gold  will  have  a  beautiful  orange  color,  which  it  will 
always  retain.  The  secretions  of  the  mouth  will  not  only 
fail  to  tarnish  it,  but  it  will  be  free  from  the  disagreeable 
taste  of  which  so  many  wearing  artificial  teeth  applied  on 
plate,  complain. 

The  process  of  finishing  having  been  conducted  thus  far, 
it  may  be  completed  by  polishing  every  part  of  the  surface 
of  the  plate,  backings  of  the  teeth,  and  clasps^  with  highly 
tempered,  and  finely  polished  steel  burnishers,  or  abrush- 
wheel,  rotten-stone,  and  jm'eZer'srowgre.*  If  burnishers  are 
used,  they  should  be  frequently  dipped  in  a  mixture  of  wa- 
ter and  castile  soap,  and  in  using,  should  be  rubbed  back- 
wards and  forwards  in  the  same  direction,  until  every  part 
of  the  gold  exhibits  a  high  polish.  Burnishers  of  different 
shapes  and  sizes  will  be  required  for  different  parts  of  the 
work. 

A  large     piece,  however,  can  be  polished  in  much   less 
time,  if  not  more  perfectly,  with  a  revolving  brush,  like  the 
one  rein-escnted  in  Fig.  198,  turned  in  a  foot-lathe,  (see  Figs. 
194  and  195,)  than  with  burnishers.     But,  before  the  rot- 
F'*»-  198.  ton-stone  is  applied,  the  brush  should 

be  lightly  smeared  with  suet,  by  hold- 
ing a  small  piece  against  it  while  it  is 
revolving.  The  rotton-stone  is  applied 
in  the  same  manner,  and  with  the  brush 
thus  charged,  the  polishing  may  com- 
mence, but  the  plate  must  not  be  ex- 
posed too  long  to  the  friction,  as  it  wears 
it  away  very  iiipidly.     After  the  piece  has  been  exposed  to 

*  Jeweler' t  rouge  ia  made  by  dissolving  copperas  in  water,  filtering  the  solution, 
and  adding  a  filtered  solution  of  pearlash,  or  subcarbonate  of  soda,  as  long  as  any 
sediment  falls.  The  liquor  is  then  filtered  again,  and  the  sediment  left  on  the  filter, 
washed  by  running  clean  water  through  it,  and  then  calcined  until  it  is  of  a  scarlet 
QoXor.—ChemiHry  of  the  Arts,  vol.  2,  p.  529. 


MANNER   OF   FINISHING   AND   APPLYING   A  PLATE.  747 

the  action  of  the  brush  until  all  the  fine  scratches  are  remov- 
ed, it  is  throughly  washed  with  a  hand-brush  in  soap  and 
water,  then  in  water,  and  afterwards  rubbed  with  a  piece  of 
soft  buckskin,  wrapped  or  sewed  around  small  blunt-pointed 
pieces  of  wood,  and  rouge,  until  every  part  is  made  brilliant. 

A  very  beautiful  finish  can  be  given  to  a  dental  substitute 
composed  of  single  teeth  mounted  on  a  base,  as  just  describ- 
ed, by  placing  a  narrow  collet  around  each  tooth,  and  sol- 
dering it  to  the  plate.  This  may  be  done  before  the  teeth 
are  united  to  the  plate  ;  and  it  may  be  made  of  gold  plate  or 
wire,  but  it  must  not  come  down  on  the  teeth  more  than  the 
sixteenth  of  an  inch.  It  may  be  so  arranged,  as  to  extend 
from  the  backing  on  one  side  of  each  tooth,  around  to  the 
same  point  on  the  other  ;  and  when  the  proj^er  care  is  used 
in  fitting  it  to  the  tooth,  it  prevents  the  introduction  of  for- 
eign matter  between  it  and  the  plate.  It  is  to  single  teeth 
what  a  rimmed  plate  is  to  gum  or  block  teeth.  But  when 
the  upper  part  of  the  teeth  will  be  exposed  in  speaking  or 
laughing,  it  ought  not  to  be  applied. 

But  the  best,  most  beautiful  and  durable  way  of  mounting 
single  teeth  without  gums,  consists  in  striking  up  a  second 
plate  over  the  first,  fitting,  backing  and  arranging  the  teeth 
on  this,  tben  marking  with  a  fine  sharp  pointed  instrument 
around  the  buccal  and  labial  sides  of  each.  The  teeth  are 
now  removed  and  the  back  part  of  the  second  plate  cut  away 
following  the  festooned  line  ;  this  must  be  done  with  perfect 
accuracy,  and  the  festooned  outer  portion  of  the  plate  is 
slightly  beveled  from  the  side  in  contact  with  the  first  plate. 
This  done,  the  two  plates  are  soldered  together,  reswaged, 
the  teeth  then  returned  to  their  proper  place,  and  united  to 
the  base  in  the  usual  manner.  The  ends  of  the  teeth  in  con- 
tact with  the  base,  when  the  work  is  executed  with  proper  ac- 
curacy, have  the  appearance  as  they  really  are^  of  being  em- 
bedded in  the  plate.* 

*  The  above  method  of  mounting  teeth,  was  introduced  bj  Dr.  Reynalds,  Den- 
tist, of  Philadelphia. 


748  MANNER   OF   FINISHING   AND   APPLYING  A    PLATE. 

In  the  application  of  teeth  prepared  in  the  manner  as  just 
described,  it  often  becomes  necessary  to  make  some  little  al- 
teration in  the  adaptation  of  the  clasps.  This,  the  operator 
can  always  effect,  if  they  have  been  attached  to  the  plate 
with  the  proper  care,  with  a  pair  of  common  pliers,  and  it 
should  be  borne  in  mind  that  they  should  never  be  so  ap- 
plied as  to  prevent  the  patient  from  removing  and  replacing 
the  piece  at  pleasure.  He  should  be  directed  to  do  this  two 
or  three  times  every  day,  and  each  time,  to  clean  the  teeth 
to  which  the  clasps  are  applied,  thoroughly,  and  it  would  be 
wellj  too,  for  the  artificial  piece  to  be  taken  out  every  night 
on  going  to  bed,  and  remain  out  until  morning. 

The  English  porcelain  teeth  are  mounted  upon  a  base  dif- 
ferently from  those  manufactured  in  the  United  States. 
They  are  attached  by  means  of  gold  wire,  soldered  to  the 
plate,  which  pass  up  through  the  teeth^  and  are  riveted  or 
soldered. 

A  substitute  for  the  incisors  and  cuspidati,  thus  mounted, 
is  represented   in  Fig.   199,  copied   from    the  work   of  Dr. 
James  Kobinson,  on  the  teeth.     This  engraving  will   con- 
Fio.  196.  YQj  a  sufficiently  correct 

idea  of  the  method  of  at- 
taching the  English  min- 
eral or  porcelain  teeth  to 
a  metallic  base,  to  render 
any  other  description  un- 
necessary. Metallic  back- 
ings, however,  riveted  and  soldered,  in  the  manner  as  be- 
fore directed,  is  a  more  secure  method  of  attachment. 


CHAPTER    ELEVENTH. 

MOUNTING  NATURAL   TEETH   UPON  A  PLATE,  OR   ME- 
TALLIC  BASE. 

Natural  teeth  may  be  mounted  on  a  plate,  constructed 
in  the  manner  as  described  for  the  porcelain,  and  secured 
by  means  of  screws  or  rivets.  The  latter  are  preferable  to 
the  former.  They  may  also  be  secured  in  the  following 
manner  :  A  gold  plate  is  made  of  the  size  of  the  space  in- 
tended to  be  supplied  with  teeth,  and  about  an  eighth  or 
sixth  of  an  inch  in  width.  To  the  inner  circle  of  this,  the 
flat  side  of  a  half-round  gold  wire  is  soldered,  each  end  ex- 
tending far  enough  back  to  form  a  clasp  around  the  tooth 
to  which  it  is  intended  to  be  applied.  The  teeth  are  next 
selected  and  fitted  on  the  model,  a  horizontal  groove  is  cut 
across  their  posterior  surfaces,  with  a  saw  or  file  of  the  same 
thickness  as  the  plate,  so  that  the  plate  may  be  let  into  them 
up  to  the  wire,  which  is  afterwards  made  fast  by  means  of 
rivets,  two  in  each  tooth.  This  done,  all  that  remains  is  to 
fit  the  ends  of  the  wire  to  the  teeth,  on  each  side  of  the  vacu- 
ity, and  around  the  ones  they  are  designed  to  encompass. 

This  method  of  mounting  natural  teeth,  however,  is  not 
so  good  as  the  one  first  described,  yet,  if  it  be  properly  done, 
and  the  mouth  in  which  they  are  placed  be  healthy,  they 
may  answer  tolerably  well  for  a  few  years.  Teeth  applied 
in  this  manner,  however,  seldom  last  very  long,  because  the 
groove  which  receives  the  plate,  admits  and  retains  the  secre- 
tions of  the  mouth,  which,  in  a  short  time,  corrode  the  teeth. 
When  teeth  are  mounted  in  the  manner  as  first  described, 
the  secretions  of  the  mouth,  it  is  true,  get  between  them  and 
the  plates,  but  then,  only  one  surface  is  exposed  to  their 


750  ATTACHING   NATURAL   TEETH   TO   A   PLATE. 

corrosive  action  ;  wliereas  when  secured  in  the  manner  as 
last  described,  three  surfaces  are  exposed_,  namely,  the  one 
which  rests  upon  the  gum,  and  one  on  each  side  of  the 
plate. 

But  the  first  method  is  preferable,  for  the  reason  that  the 
gum  is  pressed  upon  by  a  broad,  well  adapted  plate,  whereas, 
when  they  are  fastened  in  the  manner  last  described,  it  is 
pressed  upon  only  by  the  ends  of  the  teeth,  which,  as  a  ne- 
cessary consequence,  produce  more  or  less  irritation. 

Porcelain  teeth,  however,  since  the  late  improvements 
made  in  their  manufacture,,  having  almost  wholly  suj)er- 
seded  the  use  of  all  other  dental  substitutes,  it  is  not  neces- 
sary to  enter  into  a  more  minute  description  of  the  manner 
of  mounting  natural  teeth  on  plate. 

Having  now  described  the  manner  of  constructing  a  plate, 
attaching  clasps  and  teeth  to  it,  and  of  cleaning  and  finish- 
ing the  piece,  we  shall  proceed  to  notice  the  manner  in 
which  dental  substitutes  applied  in  this  way  should  be  con- 
structed— giving  a  sufficient  variety  of  cases  to  enable  the 
student  to  determine  the  proper  method  of  procedure  in  any 
one  that  may  be  likely  to  present  itself. 


CHAPTER      TWELFTH. 

DENTAL  SUBSTITUTES  FOR  SPECIAL  GASES. 

In  supplying  the  loss  of  natural  teeth  with  artificial  sub- 
stitutes, the  ingenuit}'"  and  skill  of  the  dentist  are  often 
taxed  to  their  greatest  extent.  No  two  cases  are  precisely 
alike,  and,  therefore,  no  directions  can  be  given  upon  the 
subject  from  which  it  will  not  often  be  necessary  to  deviate. 
The  illustrations,  however,  which  follow,  will,  we  trust, 
from  their  variety,  enable  the  practitioner  to  construct  an 
efficient  and  useful  substitute  for  any  teeth,  the  loss  of  which 
he  may  be  called  upon  to  replace. 


AN  ARTIFICIAL  CENTRAL  INCISOR  FOR  THE  UPPER  JAW,  MOUNTED 
ON  PLATE  WITH  ONE  CLASP. 

FiQ.  2D0. 

The  usual  method  of  applying  a  central 
incisor  on  a  metallic  base,  consists  in  ex- 
tending the  j)late  on  the  palatine  side  of 
the  teeth  on  each  side  of  the  mouth  to 
the  second  bicuspid  or  first  molar,  and  to 
secure  it  in  the  mouth  by  two  clasps,  but 
it  is  not  always  necessary  to  do  this  ;  it 
can  often  be  securely  and  firmly  fixed  by 
extending  the  plate  back  on  one  side,,  and 
clasping  it  to  a  single  bicuspid  or  molar,  and  a  piece  secured 
in  this  manner  is  frequently  worn  with  comfort  and  satisfac- 
tion for  years.  The  author  has  applied  single  teeth  in  this 
way^  when  he  found  it  necessary  to  use  clasps,  very  fre- 
quently since  1842,  and  even  two  teeth  may  often  be  secure- 
ly retained  with  one  clasp.  In  extending  the  plate  back  in 
the  mouth,  it  should  never  be  fitted  closely  around  the  necks 


752  DENTAL   SUBSTITUTES. 

of  the  teeth  behind  which  it  passes,  for  the  reason  that  it 
is  liable  to  irritate  and  inflame  the  apices  of  the  gums.  The 
author,  in  common  with  other  dentists,  was  in  the  habit  of 
doing  this  for  a  long  time,  but  observing  the  bad  eftects 
produced  by  it^  he  abandoned  the  practice  many  years  ago, 
and  has  since,  in  nearly  all  the  cases  which  he  has  had,  left 
a  space  of  about  an  eighth  of  an  inch  between  the  plate  and 
the  teeth  behind  which  it  passed^  until  it  reached  the  one  to 
which  it  was  to  be  clasped.  A  correct  idea  of  the  manner 
in  which  a  central  incisor  on  plate  is  applied,  may  be  formed 
by  an  examination  of  Fig.  200.  A  cuspidatus,  or  lateral 
incisor  or  bicuspid,,  may  be  applied  in  the  same  way^  and  if 
the  second  bicuspid  or  first  molar  is  rendered  unfit  by  dis- 
ease, to  clasp  to,  the  plate  may  be  extended  to  the  second 
molar,  or  it  may  be  even  carried  across  the  mouth,  and 
clasped  to  a  tooth  on  the  opposite  side. 

AN  ARTIFICIAL   CENTRAL  INCISOR   MOUNTED  ON  A  PLATE  WITH 

TWO  CLASPS. 

^-  ^°^'  Cases  frequently  occur 

in  which  it  is  necessary  to 
employ  two  clasps  for  the 
support  of  a  single  in- 
cisor, and  the  accompany- 
ing cut,  Fig.  201,  will 
indicate  the  description  of 
plate  most  proper  to  be 
used.  The  plate  as  here  shown,  is  extended  back,  as  may 
be  seen,  to  the  first  molar  on  each  side,  and  provided  with 
clasps  suitable  for  this  class  of  teeth. 

TWO  ARTIFICIAL  CENTRAL  INCISORS  FOR  THE  UPPER  JAW,  MOUNTED 
ON  PLATE  WITH  CLASPS. 

In  the  application  of  the  two  upper  central  incisors  on 
plate,  two  clasps,  one  on  each  side,  sometimes  become  neces- 


DENTAL  SUBSTITUTES. 


753 


sary,  althougli  they  can  often  be  securely  and  steadily  held 
in  their  place  with  one.  But  generally  two  should  be  pre- 
ferred— and  in  this  case  the  plate  may  be  extended  back, 
like  the  one  represented  in  Fig.  201,  on  each  side  along  the 
the  alveolar  ridge  to  the  first  permanent  molar,  but  if  this 
is  defective,  it  may  be  carried  to  the  second  molar,  and  in 
case  this  should  be  so  much  impaired  by  disease  as  to  ren- 
der it  unfit  to  be  clasped  to,  it  need  not  extend  further  back 
than  the  second  or  even  the  first  bicuspid.  When  the  teeth 
are  lost  on  one  side  of  the  mouthy  it  may  be  extended  back 
on  the  other,  and  secured  by  two  clasps  on  that  side,  as,  for 
example,  to  the  second  bi-  Fig.  202. 

cuspid  and  second  molar, 
or  to  any  other  two  teeth 
which  may  ofi'er  a  firmer 
and  more  secure  support. 
Fig.  202  represents  two 
central  incisors  mounted 
on  plate  and  intended  to^ 
be  clasped  to  the  first  mo- 
lar on  each  side  of  the  mouth.  For  a  similar  case  in  the 
lower  jaw,  one  clasp  mr.}-  be  made  to  hold  the  piece. 

ARTIFICIAL  INCISORS  AND  CUSPIDATI  FOR  THE  UPPER  JAW,  MOUNTED 
ON  PLATE,  "WITH  CLASPS. 

Fig.  203. 

The  construction  of 
the  plate  represented 
in  Fig.  203,  is  upon 
precisely  the  same 
principle  as  the  pre- 
ceding, and  the  only 
difference  is,  that  the 
part  of  the  plate  on 
which  the  teeth  are  mounted  fills  a  larger  vacancy  in  the 
alveolar  arch.  And,  as  in  the  former  case,  when  the  teeth 
on  one  side  of  the  mouth  are  too  much  decayed,  or  are  in- 
capable of  aff'ording  a  secure  attachment,  even  this  number 


754 


DENTAL   SUBSTITUTES. 


Fig.  204. 


of  teeth  may  be  held  by  two  clasps  on  one  side  of  the  month, 
and  they  are  often  apjilied  with  but  one,  but  whenever  this 
is  done,  the  plate  should  be  extended  half  or  three-fourths 
of  an  inch  back  of  the  tooth  to  which  it  is  clasped.  If  this 
precaution  is  neglected,  the  piece,  from  its  weight,  will  act 
as  a  lever  upon  the  tooth,  and  soon  loosen  it  and  cause  it  to 
drop  out. 

TWO  ARTIFICIAL  BICUSPIDS  FOR  THE  UPPER   JAW,  MOUNTED   ON 
PLATE  WITH  ONE   CLASP. 

The  manner  of  constructing  a  substitute  for 
two  upper  bicuspids  on  the  same  side  of  the 
mouth,  is  exhibited  in  Fig.  204,  but  when  the 
adjoining  first  molar  does  not  offer  a  suitable 
support  for  the  piece,  the  plate  may  be  extend- 
ed back  on  the  inside  of  it,  and  secured  by  a 
clasp  to  the  second,  and  if  this  also  is  diseased,  or  has  been 
removed,  the  plate  may  be  carried  across  to  the  opposite 
side  of  the  mouth,  and  secured  to  such  teeth  as  may  there 
offer  the  best  means  of  attachment.  But  in  this,  as  in  other 
similar  cases,  the  plate  should  be  thick^  and  adapted  with 
the  most  perfect  accuracy  to  the  parts  against  which  it  is  to 
rest.  If  the  clasp  or  clasps,  if  more  than  one  is  applied, 
are  of  the  proper  width,  and  well  adapted,  the  teeth  will  be 
held  firmly  in  place,  and  be  worn  without  inconvenience. 

ARTIFICIAL  BICUSPIDS  AND  FIRST  MOLARS  FOR  THE  UPPER  JAW, 
MOUNTED  ON  PLATE  WITH  CLASPS. 

^'°-  ^°^-  The  usual  plan  of  construct- 

ing a  plate  for  a  dental  sub- 
stitute like  the  one  named 
above,  is  to  cover  the  parts  of 
the  alveolar  ridge  to  be  sup- 
plied with  artificial  teeth,  ex- 
tending the  plate  across  im- 
mediately behind  the  front 
teeth,  and  confining  the  pos- 
terior extremities  with  clasps  applied  to  the  second  molars. 


DENTAL  SUBSTITUTES. 


755 


It  is  thouglit  that  greater  stability  may  be  given  to  the  piece 
by  using  two  separate  plates  and  connecting  them  together 
by  means  of  a  strip  of  thick  plate  passing  up  under  the 
palatine  arch,  in  the  manner  as  shown  in  Fig.  205.  This 
method  of  connecting  two  pieces,  was  described  to  the  au- 
thor in  1844,  by  the  late  Dr.  L.  Koper,  of  Philadelphia. 
It  will  also  be  found  valuable  for  giving  stability  to  a 
narrow  atmospheric  pressure  plate  for  an  entire  upper  set  of 
teeth . 

ARTIFICIAL  INCISORS,  CUSPIDS   AND   BICUSPIDS   FOR   THR   UPPER 
JAW,  MOUNTED   ON   PLATE,  WITH   CLASPS. 


When  the  crowns  of  the  ^"''  ^^'^^ 

first  molars  of  the  upper 
jaw  are  long,  and  well  de- 
veloped, and  in  a  healthy 
condition,  the  loss  of  the 
ten  anterior  teeth  may  be 
replaced  with  an  artificial 
substitute  that  will  sub- 
serve the  purposes  of  cor- 
rect enunciation,  as  well 
as  the  natural  organs,  and  upon  which  mastication  may  b^ 
conveniently  performed.  The  teeth,  however,  should  be 
attached  to  a  thick  strong  plate,  and  secured  to  the  first 
molars  by  broad  clasps.  They  should  also  be  correctly  and 
accurately  antagonized,  for  upon  this  will  their  utility  in  a 
great  measure  depend.  The  plate^  too,  should  extend  back 
of  the  teeth  to  which  it  is  clasped,  and  when  the  second 
molars  and  dentes  sapientiae  are  wanting,  it  may  cover  the 
whole  of  the  alveolar  ridge,  in  the  manner  as  represented  in 
.  206,  but  if  these  still  remain,  it  may  rest  upon  the 
a    ms  on  the  palatine  side,  but  without  touching  the  teeth. 


756 


DENTAL   SUBSTITUTES. 


ARTIFICIAL  INCISORS,  CUSPIDS,  BICUSPIDS,  FIRST  RIGHT,  AND  FIRST 
AND  SECOND  LEFT  MOLARS  FOR  THE  UPPER  JAW,  MOUNTED  ON 
PLATE  WITH  ONE  CLASP. 

The  dentist  is  sometimes  called  on  to  replace  the  loss  of 
upper  teeth,  when  there  is  only  a  single  molar  remaining. 
It  would,  unquestionably,  be  better,  in  cases  of  this  sort,  to 

to  remove  the  remaining 
tooth  and  apply  a  whole 
upper  set  on  the  atmos- 
pheric pressure  principle, 
but  this,  he  is  not  always 
permitted  to  do.  In  this 
case,  he  may  either  apply 
a  clasp  to  the  remaining 
tooth,  or,  what  is  perhaps 
much  better,  use  a  suction 
plate.  In  securing  a  plate 
sustaining  so  many  teeth, 
it  should  be  very  thin  and 
closely  fitted  to  the  gums. 
The  teeth,  too,  should  be  thin.  The  author  has  applied 
upper  sets  of  teeth  in  this  way,  which  are  worn  without  the 
slightest  inconvenience,  and  that  have  realized  his  most 
sanguine  expectations.  As  in  the  case  of  the  descrij^tion  of 
the  dental  substitute  last  noticed,  the  clasp  should  be  wide, 
and  accurately  fitted  to  the  tooth.  (See  Fig.  207,  in  which 
is  represented  a  set  of  teeth  of  this  descrij)tion.) 


I 


ARTIFICIAL  LATERAL  INCISORS,  AND  LEFT  BICUSPIDS  FOR  THE  UP- 
PER JAW,  MOUNTED  ON  PLATE  WITH  TWO  CLASPS  ON  ONE  SIDE. 


It  often  happens  that  there  are  several  vacuities  in  the 
alveolar  ridge  which  the  dentist  is  called  upon  to  fill,  and 
the  insertion    of  artificial  teeth    in  cases   of  this   descrip- 


DENTAL  SUBSTITUTES.  757 

tion   always   require  more  judgment   and  mechanical  tact 
and  skilly  than  in  filling  only  Pio^  208. 

a  single  aperture.  After  ob- 
taining a  plaster  model,  the 
teeth  on  it  should  be  removed 
before  metallic  casts  are 
made^  and  a  plate  swaged  up 
over  the  entire  ridge,  and  the 
parts  of  it  which  cover  the 
places  occupied  by  the  remain- 
ing teeth  filed  out  in  the 
manner  as  described  in  another  place.  The  accompanying 
cut,  however,  will  serve  to  illustrate  the  manner  of  con- 
structing dental  substitutes  in  all  cases  of  this  nature^  but 
this,  as  may  be  perceived,  is  intended  to  be  secured  in  the 
mouth  by  two  clasps  on  one  side  of  the  alveolar  ridge — all 
the  teeth  on  the  other  having  been  lost. 

The  plate  in  the  case  here  represented,  might  have  been 
extended  further  back,  and  the  first  and  even  second  molar 
replaced,  but  they  were  dispensed  with,  for  the  reason  that 
there  were  no  teeth  further  back  in  the  lower  jaw  than  the 
second  bicuspid  for  them  to  antagonise  against. 

We  have  given  the  foregoing  illustrations  of  partial  sets 
of  artificial  teeth,  as  the  use  of  clasps  are  sometimes  requir- 
ed, but  these  may  be  dispensed  with  in  at  least  nineteen 
cases  out  of  every  twenty.  It  rarely  happens  that  any  other 
support  than  suction  is  necessary. 


CHAPTER     THIRTEENTH. 

THE  TEETH  TO  WHICH  IT  IS  MOST  PROPER  TO  APPLY 
CLASPS,  AND  THE  MEANS  NECESSARY  TO  PREVENT  THE 
INJURY  LIABLE  TO  RESULT  FROM  THEIR  USE. 

Before  we  proceed  to  describe  the  manner  of  applying  a 
dental  substitute  with  spiral  springs,  or  upon  the  atmos- 
pheric pressure,  or  suction  principle,  it  will  be  proper  to  offer 
a  few  remarks  upon  the  teeth  to  which  it  is  most  proper  to 
apply  clasps,  and  the  means  necessary  to  prevent  the  inju- 
rious effects  liable  to  result  from  their  use. 

Some  teeth,  owing  to  their  situation  in  the  dental  arch 
and  the  shape  of  their  crowns,  offer  a  more  secure  means  of 
attachment  to  a  dental  substitute  retained  in  the  mouth  by 
clasps  than  others,  and  in  selecting  those  which  are  to  be 
used  for  this  purpose,  the  exercise  of  some  judgment  is  often 
called  for.  There  are  many  circumstances^  however,  which 
should  influence  the  decision  of  the  dentist  in  this  matter. 
Some  of  these  we  shall  presently  notice. 

But,  as  we  have  stated  in  another  place,  the  first  molars 
in  the  upper  jaw,  when  sound  and  securely  articulated,  offer 
a  better  means  of  support  to  a  dental  substitute,  than  any  of 
the  other  teeth,  and  when  they  can  be  as  conveniently  em- 
ployed for  this  purpose,  they  should  be  preferred.  Next  to 
these  teeth,  the  second  molars,  in  most  cases,  are  tlie  best. 
But  wlicn  neither  the  first  nor  second  can  be  used  with 
safety,  or  when  they  have  been  lost,  or  are  so  much  injured 
by  disease  as  to  render  them  an  insecure  means  of  attach- 
ment, the  second  bicuspids  may  be  employed.  After  the 
last  mentioned  teeth,  the  first  bicuspids  are  the  next  best. 


I 


TEETH   TO   WHICH   CLASPS  SHOULD   BE   APPLIED.  759 

and  when  from  the  loss  or  diseased  condition  of  these,  they 
cannot  be  used,  the  dentes  sapientiae,  if  sound,  well  devel- 
oped and  firmly  articulated,  may  be  employed. 

A  clasp  should  never  be  applied  to  a  loose  tooth,  or  to  one 
situated  in  a  diseased  socket,  or  which  is  so  much  affected 
by  caries,  as  to  render  its  perfect  restoration  and  permanent 
preservation  impracticable,  and  when  none  but  such  can  be 
had,  the  proper  course  to  pursue,  is  to  extract  every  tooth 
in  the  jaw,  and  replace  the  loss  of  the  whole  with  an  entire 
upper  set.  The  application  of  clasps  to  diseased  or  loose 
teeth,  always  aggravates  the  morbid  condition  of  the  parts, 
and  causes  the  substitute  which  they  sustain,  to  become  a 
source  of  annoyance  to  the  patient.  Besides,  such  teeth 
can  be  retained  in  the  mouth  only  for  a  short  time,  and 
when  they  give  way,  the  artificial  appliance  becomes  use- 
less, and  even  while  it  is  worn,  it  is  not  held  firmly  in  its 
place,  but  is  moved  up  and  down  by  the  action  of  the  lips 
and  tongue,  so  that  its  presence  can  hardly  escape  observa- 
tion from  the  most  careless  observer. 

The  crowns  of  tlie  cuspidati,  being  of  a  conical  shape,  are 
wholly  un suited  for  the  retention  of  clasps,  and,  conse- 
quently, should  never  be  used  for  this  purpose,  if  it  be  pos- 
sible to  avoid  it.  There  are  some  cases,  however,  in  which  it 
becomes  absolutely  necessary  to  apply  clasps  to  them,  as  for 
for  example,  when  the  loss  of  an  incisor  is  to  be  replaced  with 
a  substitute  attached  to  a  narrow  plate,  and  where  none  of 
the  back  teeth  are  lemaining  or  in  a  condition  to  be  used  as 
a  means  of  su])port  to  the  plate.  In  this  case,  the  clasps 
should  be  narrow,  and  adapted  with  the  greatest  accuracy, 
and  this  becomes  the  more  essential,  as  it  is  necessary  that 
they  should  be  short  to  prevent  being  seen.  They  should 
also  be  applied  near  to  the  gums,  but  not  near  enough  to 
touch  and  irritate  them. 

The  incisors  offer  a  poorer  means  of  attachment  for  a  den- 
tal substitute  than  any  of  the  other  teeth.  It  is  exceedingly 
difficult  to  apply  clasps  to  these  teeth  in  such  a  manner  as 
to  retain  even  a  single  tooth  with  sufficient  stability  to  be 


760  TEETH   TO   WHICH   CLASPS  SHOULD   BE   APPLIED. 

worn  with,  any  degree  of  comfort,  yet  when  they  are  the 
only  ones  that  can  be  used,  it  may  sometimes  be  necessary 
to  apply  them  even  to  these  teeth,  but  only  as  a  dernier 
resort. 

Finally,  there  are  many  circumstances  which  it  is  necessary 
to  take  into  consideration  in  the  selection  of  teeth  to  be  used 
as  a  means  of  support  for  artificial  teeth.  For  example,  a 
space  should  never  be  filed  between  two  sound  molar  or  bi- 
cuspid teeth  for  the  purpose  of  applying  a  clasp,  if  there  is 
another  tooth  around  which  it  can  be  plased  without  this  op- 
eration. The  liability  of  a  tooth  to  decay,  to  which  a  clasp 
is  applied,  is  always  greatly  increased  by  the  removal  of  a 
portion  of  its  substance.  Hence,  the  separation  of  two  teeth 
with  a  file,  with  a  view  to  the  application  of  a  clasp  to  one 
of  them,  should  never  be  resorted  to^  if  it  be  possible  to 
avoid  it. 

With  regard  to  the  lower  jaw,  parts  of  sets  are  much  less 
frequently  called  for  here  than  in  the  upper,  and  when  they 
are,  the  use  of  clasps  may  be  often  dispensed  with  altogether. 
But  it  sometimes  becomes  necessary  to  use  them,  and,  as 
a  general  rule,  they  can  be  more  conveniently  applied  to  the 
bicuspids  than  the  molars  or  cuspids.  A  clasp  can  seldom 
be  applied,  advantageously,  to  a  lower  molar. 

If  the  injurious  effects  liable  to  result  from  the  application 
of  clasps  to  teeth,  could  not,  in  any  way,  be  counteracted, 
dental  substitutes,  maintained  in  the  mouth  by  this  means, 
would,  in  the  majority  of  cases,  be  productive  of  more  inju- 
ry than  benefit.  But,  fortunately,  the  deleterious  effects 
liable  to  result  from  them  may,  in  most  cases,  to  some  ex- 
tent at  least,  be  prevented.  They  are  not  produced,  as 
many  have  erroneously  supposed,  by  the  mechanical  action 
of  the  clasps  upon  the  teeth,  but  by  the  chemical  action  of 
the  secretions  of  the  mouth,  and  other  extraneous  matter  re- 
tained between  the  two. 

The  cause  of  this  destructive  action,  then,  being  chemical, 
and  not  mechanical,  the  means  of  preventing  its  deleterious 
effects,  are  obvious.     They  consist,  as  we  have   stated  in 


TEETH   TO   WHICH    CLASPS  SHOULD   BE   APPLIED.  761 

another  place,  in  the  frequent  removal  of  the  artificial  teeth, 
and  thoroughly  cleansing  the  natural  organs  used  as  a 
means  of  support  for  them.  This  should  be  done  every 
morning  and  night  and  after  each  meal.  For  which  pur- 
pose^ a  brush  and  waxed  floss  silk  may  be  employed,  and 
the  teeth  rubbed  until  every  particle  of  clammy  and  vitiated 
mucus  and  foreign  matter  is  removed.  The  inner  surface 
of  the  clasps,  too,  should  be  freed  from  all  impurities,  and 
the  whole  piece  cleansed  with  a  brush  and  water. 

The  clasps  should  always  be  so  constructed,  that  they 
may  be  removed  with  ease  by  the  patient.  But  the  effects 
arising  from  the  presence  of  corrosive  agents  are  not  the 
only  deleterious  consequences  liable  to  be  produced  by 
clasps.  They  are  often  fitted  and  applied  in  such  a  manner 
as  to  force  themselves  up  upon  the  necks  of  the  teeth  and 
gums,  causing  inflammation  of  the  latter,  as  well  as  that  of 
the  alveolo-dental  membrane,  and,  ultimately,  the  destruc- 
tion of  the  alveoli  and  loss  of  the  teeth.  The  same  effects, 
too,  are  produced  when  they  act  as  retractors .  Hence,  the 
necessity  of  adjusting  them  in  the  most  perfect  manner. 


49 


CHAPTER    FOURTEENTH. 

DOUBLE    SET    OF    ARTIFICIAL    TEETH    MOUNTED    OiX 
PLATE    WITH    SPIRAL    SPRINGS. 


Fig-  209.  By  a  double  set  of  artificial 

teeth,  is  meant  a  substitute 
for  all  or  the  greater  part  of 
the  natural  teeth  of  both  jaws. 
They  are  sometimes,  though 
now  very  rarely,  confined  in 
the  mouth  with  spiral  springs, 
one  on  each  side,  attached  at 
each  end,  to  each  circle  of 
teetli.  Wlien  correctly  con- 
structed, and  applied  under  favorable  circumstances,  tliey 
are  valuable  substitutes  for  the  natural  organs,  but  when 
badly  constructed,  as  they  frequently  are,  and  applied  under 
unfavorable  circumstances,  they  are  productive  of  more  or 
less  inconvenience  and  annoyance  to  the  patient. 

It  often  happens,  that  the  loss  of  the  teeth  is  occasioned 
by  disease  in  the  gums  and  alveolar  processes,  and  when  this 
is  the  case,  the  latter  are  so  much  wasted  and  destroyed  that 
the  ridge  in  tlic  lower  jaw  is  scarcely  perceptible  and  becomes 
covered  with  loose  folds  of  mucous  membrane.  Tlic  appli- 
cation of  a  useful  dental  substitute,  under  such  circum- 
stances, is  sometimes  attended  with  difficulty.  The  ])ressure 
of  the  piece  is  apt  to  cause  irritation.  But  this  may,  in 
mo|t  cases,  be  prevented  by  using  a  thick  plate,  fitted  accu- 
rately to  the  parts  and  extended  back  upon  the  coronoid 
l)rocesses.  It  should  also  be  applied  without  springs. 
The  upper  plate  may  be  about  one  inch  in  width,  and  the 


DOUBLE   SET   OF    ARTIFICIAL   TEETH,  763 

lower  as  wide  as  tlie  ridge  will  admit  of  its  being  made,  and 
three  times  as  thick  as  the  upper,  and  of  gold  at  least 
twenty-two  carat  fine.  Twenty  carat  gold  may  be  used  for 
the  upper  plate. 

After  having  obtained  a  correct  antagonizing  model,  the 
operator  places  a  rim  of  beeswax  on  each  plate  against 
which  the  teeth  are  arranged  as  he  selects  them,  beginning 
with  the  central  incisors,  the  upper  first,  then  the  lower, 
next  the  laterals,  afterwards  the  cuspids  and  bicuspids, 
and,  lastly,  the  first  and  second  molars — twenty-eight  being 
the  number  usually  employed  for  an  artificial  set. 

After  the  teeth  have  been  arranged,  and  fitted  to  the 
plates,  and  the  gold  backings  put  on,  they  may  be  secured 
with  plaster  ;  the  wax  is  then  removed,  and  the  process  of 
soldering  and  finishing  performed  in  the  manner  as  already 
described. 

But  before  the  teeth  are  soldered  on,  the  attachments  for 
the  springs  are  made  fast  to  the  outer  edge  of  the  plates  on 
each  side,  against  the  second  bicuspids,  or  partly  between 
them  and  the  first  molars.  The  description  of  attachments 
which  the  author  prefers,  so  regulates  the  motions  of  the 
springs,  that  they  are  prevented  from  coming  in  contact 
with  the  outer  surface  of  the  alveolar  ridge  on  the  outside 
of  the  plate,  or  from  turning  out  towards  the  cheek,  and 
irritating  the  mucous  membrane.  Their  construction  is  so 
plainly  exhibited  in  the  accompanying  cut,  as  well  as  that 
of  the  eyelets  and  springs,  that  no  other  description  is 
deemed  necessary. 

Fig.  210. 


The  principle  on  which  the  springs  act,  may  be  seen  in 
Fig.  209,  by  which  it  will  be  perceived  the  upper  and  lower 
rows  of  teeth  are  constantly,  but  gently  pressed  against  the 
parts  on  which  they  rest. 


764  DOUBLE  SET   OF   ARTIFICIAL    TEETH. 

The  lengtla  of  the  springs  must  be  determined  by  the  dis- 
tance of  the  jaws  from  each  other  when  the  mouth  is  opened. 
In  some  cases  it  is  necessary  to  have  them  much  longer  than 
in  others.  The  usual  length,  however,,  is  from  an  inch  and 
a  half  to  two  inches. 

It  often  happens  that  six  or  eight  teeth  in  the  front  part 
of  the  mouth  in  the  lower  jaw  remain  healthy  and  firmly 
fixed  in  their  sockets,  after  all  the  other  teeth  are  lost.  In 
this  case,  the  lower  plate  may  be  so  constructed  as  to  cover 
the  unoccupied  portions  of  the  alveolar  ridge,  and  to  fit  its 
upper  and  inner  surface  behind  the  remaining  natural  teeth. 
This  part  of  the  plate  is  strengthened  by  soldering  to  it 
another  plate  of  equal  or  even  greater  thickness. 

But  when  the  lower  incisors^  cuspids,  and  two  of  the  bicus- 
pids are  remaining,  it  is  better  to  dispense  with  the  others 
than  encumber  this  part  of  the  mouth  with  artificial  sub- 
stitutes. The  upper  teeth  may  be  replaced,  but  not  the 
lower,  and  when  there  are  but  six  remaining  in  the  inferior 
maxillary,  it  would  be  better  to  remove  them  and  apply  an 
entire  dental  apparatus,  as  it  is  exceedingly  difficult  and 
sometimes  impossible  to  replace  the  others  in  such  a  way  as 
to  render  them  serviceable  while  the  front  part  of  the  jaw  is 
occupied  with  natural  teeth,  especially  when  retained  in 
place  by  means  of  spiral  springs. 


CHAPTER      FIFTEENTH. 

ARTIFICIAL  TEETH  MOUNTED  ON  SUCTION  OR  ATMOS- 
PHERIC BASES. 

The  engraving,  Fig.  211,  represents  the  appearance  of  a 
dental  substitute  for  all  the  upper  teeth,  when  ready  to  be 
put  in  the  mouth,  and  Fig.  212  the  plaster  model  of  the 
alveolar  ridge  and  roof  of  the  mouth  of  the  individual  for 
whom  the  teeth,  from  which  the  first  of  these  drawings 
was  made,  were  intended.  The  only  difference  between 
teeth,  applied  upon  this  principle  and  with  spiral  springs, 
is,  the  plate  in  the  former  is  rather  wider  than  in  the  latter. 
It  covers  the  whole  of  the  outer  surface  of  the  alveolar 


Fig.  211. 


Fig.  212. 


ridge,  and  a  considerable  portion  of  the  roof  of  the  mouth,  but 
it  need  not  go  as  far  back  as  many  dentists  are  in  the  habit 
of  extending  it,  for  the  reason  that  a  very  wide  plate  cannot 
be  as  perfectly  and  accurately  adapted  to  the  parts  as  one 
of  moderate  width.     Unless  it  be  made  to  touch  every  por- 


766  ARTIFICIAL   TEETH   ON   ATMOSPHERIC   BASES. 

tion  of  the  surface  wliicli  it  covers,  it  will  be  constantly 
liable  to  drop.  A  narrow  plate,  well  fitted,  will  adhere 
more  firmly  than  a  very  wide  one,  imperfectly  adapted. 
The  successful  application  of  artificial  teeth,  upon  this 
principle,  depends  ujDon  having  the  plate  accurately  adapted 
to  the  parts  upon  which  it  is  to  rest. 

However  accurately  a  plate  may  be  made  to  fit  the  model, 
it  is  sometimes  warped  in  soldering  the  teeth  to  it,  destroy- 
ing its  adaptation  and  causing  it  to  rock  when  placed  in  the 
mouth.  When  this  happens,  it  cannot  be  made  to  adhere 
to  the  gums,  and  consequently  cannot  be  worn  with  com- 
fort. For  the  restoration  of  the  plate,  a  variety  of  means 
have  been  proposed.  The  one  which  the  writer  has  found 
most  successful,  consists  in  binding  it  to  the  plaster  model 
with  a  fine  iron  wire  in  such  a  way  that  it  shall  be  made  to 
touch  every  part  it  covers  ;  then  to  heat  the  piece  to  a  cherry 
red  heat  with  the  flame  of  a  lamp  applied  with  a  blow- 
pipe. 

The  springing  of  the  plate  in  soldering  on  the  teeth  being 
caused  by  unequal  expansion  of  the  gold,  it  might  nearly 
always  be  prevented  by  annealing  it  after  the  swaging  has 
been  completed.  In  striking  up  the  plate,  some  parts  are 
acted  upon  and  hardened  more  than  others^  and  this  is  the 
cause  of  its  unequal  expansion.  It  is  also  important  that 
the  gold  placed  upon  the  teeth  should  be  annealed  before 
being  soldered  to  the  plate.  But  with  all  the  care  and  pre- 
caution that  can  be  used,  it  is  not  possible,  in  every  case, 
to  secure  absolute  accuracy  of  adaptation,  as  the  dies  between 
which  the  plate  are  swaged  are  necessarily  more  or  less 
bruised  in  this  part  of  the  operation. 

In  the  application  of  a  double  set,  on  this  principle,  the 
lower  plate  should  be  as  wide  and  long  as  the  alveolar 
ridge  of  the  inferior  maxilla  will  admit  of  its  being  made. 
Fig.  213  represents  a  dental  substitute  of  this  description  in 
an  antagonizing  model  of  plaster  of  paris.  The  posterior 
extremities  of  the  lower  plate,  as  may  be  perceived,  extend 
up  about  half  an  inch  on  the  coronoid  processes.     The  lower 


ARTIFICIAL   TEETH    ON   ATMOSPHERIC   BASES. 


767 


alveolar  ridge  of  the  individual,    (a  lady,)  for  whom  the 

original  was  constructed,  is  al-  Fn.  213. 

most  wholly  wanting,  and  each 

side  is  covered  with  loose  folds 

of  mucous  membrane,  so  irritable 

as    to  pi-event  the    patient  from 

wearing   artificial    teeth   applied 

with  springs.     She  has  worn  the 

set  here  represented  many  years 

without  having  experienced   the 

slightest  inconvenience. 

In  the  substitution  of  artificial  for  the  loss  of  the  natural 
teeth,  of  either  or  both  jaws,  this  method,  when  it  can  be 
advantageously  adopted,  and  tliere  are  few  cases  in  which 
it  cannot  be,  is  preferable  to  any  other. 

When  the  teeth  are  put  in  the  mouth,  the  patient  is 
directed  to  exhaust  the  air  from  between  the  plate  or  j)lates, 
when  a  double  set  is  applied,  and  gums,  which,  if  properly 
fitted,  will  at  once  cause  them  to  adliere,  though  not  imme- 
diately with  as  much  tenacity  as  they  will  after  having  been 
worn  a  few  days  or  weeks. 

It  is  not  always  necessary 
to  employ  a  very  wide  plate 
to  secure  a  sufficient  amount 
of  suction  for  its  retention. 
A  comparatively  narrow  one 
may  often  be  made  to  adhere 
with  very  great  tenacity  to 
the  gums.  But  a  plate  of 
this  kind  is  more  liable  to  be 
bent,  and  lose  its  perfect  adap- 
tation to  the  parts  than  a 
wide  one.  Its  liability  to  be 
injured,  however,  in  this  way,  may  be  measurably  pre- 
vented by  extending  a  piece  across  from  one  side  to  the 
other,  under  the  palatine  arch,  in   the  manner  as  recom- 


FlG.  214. 


768 


ARTIFICIAL   TEETH   ON    ATMOSPHERIC   BASES. 


mended  by  Dr.  Roper  for  two  or  three  teeth  on  each  side  of 
the  jaw,  as  shown  in  Fig.  214.  In  this  way_,  great  stability 
may  be  given  to  a  plate  for  an  upper  circle  of  teeth,  without 
encumbering  the  mouth  with  a  wide  plate.  It  may  also  be 
used  with  great  advantage  in  cases  where  it  is  necessary  to 
employ  spiral  springs. 

In  replacing  the  loss  of  the  bicuspids  and  molars  of  the 
upper  jaw  witli  artificial  substitutes^  mounted  upon  an 
atmospheric  or  suction  plate,  increased  stability  may  be 
given  to  the  piece  by  constructing  and  adjusting  the  plate  in 
such  a  manner  that  a  narrow  band  shall  pass  in  front  of  the 


FiQ.  216. 


Fig.  216. 


alveolar  border,  as  represented  in  Fig.  215,  but  this  should 
fit  with  great  accuracy  to  prevent  irritating  the  gums. 
This  method  of  constructing  and  applying  atmospheric 
plates  was  recommended  to  the  author  by  Dr.  G.  E.  Hayes, 
of  Buffalo,  ]Sr.  Y.  In  Fig.  210  is  represented  a  substitute 
for  all  tlio  upper  teeth  except  the  dentes  sapientiae,  con- 
structed upon  the  same  principle. 


ARTIFICIAL    TEETH   WITH   GUMS,    MOUNTED   ON   PLATE.       TGO 


In  the  application  of  one  or  two 
teeth  npon  this  princiijle,  it  is  neces- 
sary to  employ  a  very  wide  plate,  in 
order  to  present  as  much  surface  for 
the  atmosphere  to  act  upon  as  possihle. 
A  substitute  for  the  two  central  in- 
cisors mounted  upon  a  single  plate,  to 
be  applied  upon  this  principle,  is  rep- 
resented in  Fig.  217. 


Fig.  217. 


ARTIFICIAL   TEETH  WITH  GUMS,  MOUNTED  ON  PLATE. 


The  loss  of  the  teeth  is  some-  ^'o-  218. 

times  followed  by  the  destruction  iSp^ 
of  more  or  less  of  the  alveolar  '     ^ 
border.     When  this  hajDpens,  in 
furnishing   a   substitute   for  the 
former,  it  often  becomes  necessary 
for  the  restoration  of  the  contour 

of  the  face,    to   replace  the   latter  ;  and    for  doing  which 
several  methods  of  proce  lure  have  been  adopted. 

When  ivory  was  empl  )yed  for  artificial  teeth,  and  as  bases 
for  the  support  of  dental  substitutes,  it  was  carved  in  such  a 
manner  as  to  imitate  the  shape  of  the  gums,  and  afterwards 
colored.  But  the  use  of  this  substance  for  purposes  of  this 
kind,  has  been  wholly  abandoned,  or  very  nearly. 

Eaised  plates  have  also  been  employed,  and  these  may 
often  be  made  to  answer  a  very  good  purpose,  but  since  the 
invention  of  porcelain  teeth,  a  much  better  substitute  for  the 
alveolar  border  and  gums  has  been  used.  Poicelain  teeth 
may  be  manufactured  either  singly  or  in  blocks,  with  a  base, 
colored  and  enameled  on  the  exterior  or  labial  surface, 
forming  a  most  excellent  substitute  for  the  lost  stiuctures, 
and  imitating  nature  so  closely  as  almost  to  preclude  the 
possibility  of  detection.  It  has  been  customary  among  den- 
tists manufacturing  their  own  porcelain  or  mineral  teeth,  in 
the  construction  of  an  entire  set,  or  a  series  for  the  same 


770      ARTIFICIAL  TEETH    WITH   GUMS,  MOUNTED   ON   PLATE. 

jaw,  to  fabricate  them  in  blocks,  but  as  few  dentists  possess 
the  means  and  necessary  knowledge  and  practical  experience 
for  doing  this,  and  as  there  are  some  cases  in  which  they 
cannot  be  advantageously  employed,  a  few  remarks  on  the 
use  of  single  gum  teeth  may  not  be  out  of  place.  In  a  sub- 
sequent chapter,  the  method  of  making  and  mounting  block 
teeth,  will  be  described. 

A  little  more  time  and  tact  are  required  in  fitting  the 
teeth  to  each  other,  and  to  the  plate,  than  for  the  manufac- 
ture of  blocks,  but  when  properly  adjusted  and  attached  to 
the  plate,  they  answer,  in  very  many  cases,  almost  as  good 
a  purpose^  and  if  by  any  accident,  one  or  two  of  the  teeth 
are  broken,  they  may  be  more  easily  replaced. 

But  in  the  construction  of  a  piece  composed  of  single 
teeth,  they  should  be  fitted  to  each  other  and  the  plate  in 
the  most  perfect  and  accurate  manner,  so  that  no  lodgments 
may  be  afforded  for  j^articles  of  food  or  extraneous  matter  of 
any  kind.  In  Fig.  218,  is  represented  an  atmospheric  pres- 
sure or  suction  substitute  for  all  the  teeth  of  the  upper  jaw, 
composed  of  single  gum  teeth,  mounted  upon  a  broad  plate. 
In  Fig.  219  is  seen  a  representation  of  a  set  of  gum  teeth  for 
the  superior  maxillary,  mounted  on  a  base  of  the  same  kind, 
with  the  outer  edge  of  the  plate  turned  down  on  the  teeth. 

'"■    ^^'  It  sometimes  happens  in  the 

application  of  a  substitute  for  all 
the  teeth  of  the  upper  jaw  upon 
the  atmospheric  principle,  tliat 
tlie  lidge  is  so  prominent  as  to 
preclude  the  use  of  gum  teeth, 
and  to  expose  the  plate  covering 
the  anterior  part  of  it,  whenever  the  mouth  is  opened  in 
speaking  or  laughing.  To  obviate  this,  it  has  been  recom- 
mended to  cover  the  anterior  margin  of  the  plate  and  inter- 
spaces between  the  teeth  with  a  terra-metallic  paste,  fusible 
at  a  very  low  temperature,  and  afterwards  covered  with  gum 
enamel.     The  following  formula  is  given  by  M.  Delabarre 


ARTIFICIAL   TEETH    WITH   GUMS,  MOUNTED    ON   PLATE.       Y71 

for  this  purpose  :  porcelain  paste  1  oz.,  white  silex  half  oz., 
any  oxyd  10  grs.,  and  a  sufficient  quantity  of  calcined 
gypsum  to  give  to  it  the  necessary  degree  of  fusibility.  As  a 
suitable  enamel,  Desirabode  recommends,  feldspar  2  drachms, 
oxyd  of  gold  6  grs.,  kaolin  6  grs.  But  neither  of  these 
formulas  can  be  used  on  gold  plate,  nor  in  connection  with 
American  porcelain  teeth,  as  too  high  a  heat  is  required  for 
their  fusion.  Drs.  Hunter  and  Allen,  of  Cincinnati,  Ohio, 
however,  have  succeeded  in  making  a  silicious  composition, 
which  can  be  used  on  gold  slightly  alloyed  with  platina. 
The  manner  of  working  this  will  be  described  in  a  subse- 
quent chapter. 


CHAPTER    SIXTEENTH. 

ARTIFICIAL  TEETH  MOUNTED   ON  CAVITY  PLATES. 

A  METALLIC  base  for  artificial  teeth  may  be  made  to  adhere 
to  the  gums  with  greater  tenacity  by  having  it  constructed 
with  a  cavity  opening  upon  them,  than  by  simple  coadapta- 
tion,  however  accurately  the  plate  may  be  made  to  fit. 
Still,  in  the  majority  of  cases,  it  may  be  made  to  adhere 
with  sufficient  tenacity  for  all  useful  and  practical  purposes, 
and  if  a  plate  of  this  kind  can  be  so  applied  as  to  secure 
perfectly  the  atmospheric  principle,  no  advantage  whatever  is 
derived  from  a  chamber  in  the  plate,  opening  upon  the 
gums.  But  this,  in  many  cases,  is  found  to  be  impractica- 
ble, for  the  reason  as  stated  by  Dr.  Dwindle,  that  when 
the  plate  is  applied,  and  an  effort  made  to  exhaust  the  air 
from  between  it  and  the  gums,  the  latter,  "along  the  line, 
and  behind  the  edge  of  the  former,  are  drawn  down  so  as  to 
meet  it,"  thus  resisting  every  effort  made  from  without  to 
withdraw  the  air  from  the  central  part  of  the  plate_,  so  that 
the  pressure  of  the  atmosphere  is  only  exerted  upon  a  small 
breadth  of  surface,  along  the  edge  of  it,  where  the  suction 
is  constantly  liable  to  be  disturbed  in  biting  upon  the  teeth. 
With  a  view  of  obviating  this  difficulty,  the  idea  of  con- 
structing a  plate  with  a  cavity,  suggested  itself  to  the  writer 
as  early  as  1835,  which  he  mentioned  at  the  time  to  several 
of  his  professional  brethren,  but  as  the  construction  of  the 
chamber  which  he  then  devised  was  found  objectionable,  he 
abandoned  the  use  of  it,  and  it  was  not  until  the  early  part 
of  1848,  when  he  had  an  opportunity  of  seeing  a  cavity  plate 
contrived  by  Dr.  J,  A.  Cleaveland,  that  he  was  again  in- 
duced to  construct  a  base  of  this  sort.    Dr.  C.  had  construct- 


ARTIFICIAL   TEETH   MOUNTED    ON  A   CAVITY   PLATE.  773 

ed  cavity  plates  two  or  three  years  previously  to  this  time. 
Dr.  W.  H.  Dwindle  made  a  cavity  plate  with  an  external 
opening  and  valve  for  exhausting  the  air,  in  the  winter  of 
1845  ;  and  in  the  summer  of  1847,  or  '48,  Dr.  Jahial  Parmly 
exhibited  to  the  author  a  plate  with  a  simple  cavity  struck 
into  it  in  swaging.  Some  months  after,  he  heard,  for  the 
first  time,  of  a  cavity  plate,  contrived  and  patented  by  Mr. 
Grilbert,  of  New  Haven. 

The  cavity  in  most  of  the  plates  now  employed,  is  formed 
nearly  in  the  centre,  or  immediately  behind  the  alveolar 
ridge,  but  Dr.  J.  F.  B.  Flagg,  a  dentist  of  Philadelphia, 
has  recently  added  two  lateral  cavities,  which  is  said  to 
prevent  the  plate  from  rocking,  and  to  give  to  it  increased 
stability. 

Having  premised  these  few  remarks  on  the  subject  of  cav- 
ity plates,  we  shall  proceed  to  give  a  brief  description  of  the 
manner  of  constructing  them  ;  beginning  first  with  the 
cavity-plate  and  valve  of  Dr.  Dwindle. 

To  the  plaster  model,  a  piece  of  wax  about  an  eighth  of 
an  inch  thick  in  the  centre,  and  five-eighths  in  diameter,  but 
gradually  diminishing  to  the  periphery,  is  placed  just  be- 
hind the  alveolar  border.  With  the  model  thus  prepared, 
a  metallic  model  and  counter  model  are  obtained.  A  plate  is 
then  struck  up  in  the  usual  way,  then  with  a  very  small  drill 
a  hole  is  made  through  the  central  part  of  the  cavity,  or  rais- 
ed part  of  the  plate.  This  is  next  reamed  out  to  a  cone  shape, 
the  base  terminating  outwards,  and  not  exceeding  half  a 
line  in  diameter.  A  piece  of  gold  wire  as  large  as  the  base 
of  the  hole  is  now  taken,  and  filed  down  in  a  small  jeweler's 
bow-lathe  until  it  nearly  fits  the  conical  hole  in  the  plate, 
leaving  an  extension  to  pass  up  through  the  plate  in  the 
form  of  a  stem.  It  is  again  placed  in  the  lathe  and  ground 
down  with  powdered  scotch  stone  and  oil,  until  it  fits  the 
cone-shaped  hole  in  the  plate  so  perfectly  as  to  render  it 
completely  air-tight ;  the  base  is  then  filed  down  to  a  level 
with  the  plate. 

The  method  which  Dr.  Dwindle  adopted  for  securing  this 


774         ARTIFICIAL   TEETH    MOUNTED   ON    A    CAVITY    PLATE. 

valve  is  as  follows,  we  copy  liis  own  description:  "Hav- 
ing rolled  down  a  piece  of  gold  to  exceeding  thinness,  we 
cut  out  a  piece  in  the  form  of  a  cross  ;  at  the  centre,  where 
the  angles  met,  we  punctured  a  hole  to  receive  the  stem 
of  the  valve  bending  the  four  extremities  downwards 
equally,  we  formed  what  artizans  would  call  a  spider-leg 
spring.  Now,  the  valve  being  in  its  place,,  we  placed  the 
spring  immediately  over  it,  on  the  upper  surface  of  the  plate, 
and  pressed  it  down — the  stem  of  the  valve  passing  through 
the  hole  in  the  centre  of  the  spring,  until  it  reached  within 
about  half  a  line  of  the  plate  ;  with  a  small  pair  of  forceps, 
we  then  seized  the  stem  above  the  spring,  and  by  pressure, 
flattened  it  down,  so  as  to  forma  kind  of  head,  thus  detain- 
ing it  attached,  and  holding  it  to  its  place."  Dr.  D.  states, 
however,  that  he  has  subsequently  used  a  spring  made  of  a 
single  strip  of  gold,  with  one  end  attached  to  the  plate^  like 
a  tongue  to  an  accordeon,  making  a  simple  slit  in  the  end 
of  it  for  the  reception  of  the  stem  of  the  valve.  He  also 
recommends  that  a  piece  of  plate  be  soldered  on  the  part  of 
the  chamber  pierced  by  the  hole  to  increase  its  thickness. 

Fig.  220.  Fig.  221.  t      T?-        oon  •  *   J 

in  Jj  ig.  220  IS  represented  an  en- 
larged view  of  the  valve  and  socket 
a  a  without  the  spring  ;  also  show- 
ing the  raised  part  of  the  plate  b  h,  in  which  the  conical 
valve  a  a  is  fitted.  In  Fig.  221,  the  valve  spring  and  plate 
combined,  are  represented. 

In  exhausting  the  air  from  the  cavity,  and  between  the 
plate  and  gums,  the  valve  is  drawn  down,  which  gives  it 
an  opportunity  of  escaping,  but  the  instant  it  passes  up  to 
its  place,  its  further  egress,  and  ingress  from  without,  is 
prevented.* 

The  next  description  of  cavity  plate  which  we  propose 
to  notice  is  the  one  contrived  by  Dr.  J.  A.  Cleaveland, 
and  the  following  is  the  method  of  procedure  in  its  con- 
struction : 

♦  Vide  Dr.  Dwinelle  on  Cavity  Plates,  in  No.  2,  vol.  x,  Amer.  Jour,  of  Den.  Sci. 


ARTIFICIAL   TEETH    MOUNTED    ON   A   CAVITY   PLATE.         775 

A   metallic   model    and  counter-model  having  been  ob- 
tained, a  plate  is  struck  up  covering  the  entire  alveolar  bor- 
der and  extending  back  as  far  as  the  termination  of  the 
hard  palate.     This  done,  it  is  placed  in  the  mouth_,  and 
if  it  be  found  to  be  accurately  adapted  to  the  parts  against 
which  it  is  placed,  it  may  be  removed^  and  a  piece  of  half 
round  wire  of  the  same  metal,  as  large  as  a  common  sized 
knitting  needle,  soldered  to  the  lower  side  of  the  plate,  im- 
mediately behind    the   alveolar    ridge,   describing   a   circle 
about  the  size  of  an  American  twenty-five  cent  piece.     The 
part  within  the  circle  is  next  removed  ;  the  plate  then  placed 
on  the  model,  and  a  piece  of  softened  beeswax,  about  a  tenth 
or  twelfth  part  of  an  inch  in  thickness,  having  a  circumfer- 
ence one-fourth  greater  than  the  hole  in  the  plate,  is  placed 
over  the  opening,  extending  a  short  distance  beyond  the 
■wire  on  every  side.     At  the  periphery  it  is  brought  to  a  thin 
edge,  and  is  much  thinner  in  the  centre  than  where  it  covers 
the  wire  surrounding  the  opening  in  the  plate.     A  wax  im- 
pression of  the  model,  plate  and  wax  covering  the  opening 
in  it,  is   next  taken.     From  this,  a  ])laster  and  metallic 
model  and  counter-model  are  obtained.     A  thin  plate  of 
gold,  if  the   first  plate  be  ol'  this  metal,  large  enough  to 
cover  the  wax  on  the  first  plate,  is  now  struck  up  ;  the  wax 
is  next  removed  from  the  first  plate,  and  the  last  soldered  to 
it,  when,   if  the  piece  be  applied  to  the  mouth  and  the  air 
exhausted,  it  will  be  found  to  adhere  with  great  tenacity. 

Fig.  222. 

A  sectional  view  of  the  "       "    ' 

'cavity    is    represented   in 
Fig.  222. 

The  principal  ad  van-  l!§i|P^ 
tage  of  Dr.  Cleaveland's  w*^ 
cavity  plate,  is  this  :  by  the  union  of  two  plates,  the  lia- 
bility of  disturbing  that  portion  of  the  base  which  covers 
the  roof  of  the  mouth,  in  biting  against  the  teeth  is  greatly 
diminished. 


776         ARTIFICIAL   TEETH   MOUNTED   ON   A    CAVITY   PLATE. 

The  base  being  thus  preparecl_,  the  teeth  may  be  mounted 
upon  it  in  the  manner  described  in  a  preceding  chapter. 

The  simple  cavity  plate  employed  by  Dr.  Jahial  Parmly, 
of  New  York,  and  patented  by  Mr.  Gilbert_,  of  New  Haven, 
may  be  formed  with  as  much  ease  as  the  ordinary  plate, 
and  in  most  cases,  will  answer  as  well  as  any  other  descrip- 
tion of  cavity  plate.  The  method  of  procedure  in  forming 
a  plate  of  this  sort  is,  first,  to  place  a  piece  of  softened  wax 
on  the  model,  over  the  median  line,  immediately  behind  the 
alveolar  border.  In  the  centre  it  should  be  about  the  tenth 
part  of  an  inch  in  thickness,  gradually  diminishing  to  the 
circumference,  and  about  three-fourths  of  an  inch  in  diame- 
ter. With  the  model  thus  prepared  an  impression  is  made 
in  sand,  and  a  metallic  model  and  counter-model  procured. 
This  done,  the  plate  is  struck  up  in  the  usual  way,  and  the 
teeth  arranged,  fitted  and  attached  to  it,  in  the  manner 
already  described. 

Fig.  223.  In  ^ig.  223  is  represent- 

ed  a  sectional  view  of  a 
ion. 


■:i':'!'!i'iliiiiJiliJi|'iii'f;i;i!;:ini;;'M A^  ^d   a  sectional  view  i 

'""^^^'■'^^^^isM^m     ^^^*®  ^^  ^^"'^  descript 


If   it  is   desired   to  have 
IllfP  lateral   chambers   in    the 


plate,  three  pieces  of  wax 
are  placed  on  the  plaster  model  instead  of  one.  One  may 
be  placed  in  the  centre^  as  already  described,  and  one  on 
the  alveolar  ridge  on  each  side.  But  this  can  only  be  done 
in  forming  a  plate  for  the  upper  jaw.  A  plate  for  the  lower 
jaw  can  only  have  lateral  chambers,  but  these  may  extend 
forward,  and  even  meet  in  front. 

The  remarks  which  we  have  thus  far  made  upon  cavity 
plates,  apply  to  a  base  for  a  substitute  for  all  the  teeth  of 
one  jaw  ;  but  increased  adhesion  and  stability  of  such  pieces 
are  not  the  only  advantage  gained  by  the  use  of  this  des- 
cription of  plate.  With  a  cavity  plate,  the  loss  of  a  single 
tooth,  or  any  number  of  teeth,  may,  in  most  cases,  be  re- 
placed without  the  aid  of  clasps,  and  when  this  last  means 


^ 


ARTIFICIAL   TEETH   MOUNTED   ON   A   CAVITY   PLATE.         777 

of  support  for  artificial  teeth  can  be  dispensed  with,  it  should 
he  done.  The  deleterious  effects  liable  to  result  from  their 
use  have  already  been  noticed.  So  successful  has  the  use  of 
cavity  plates  been  in  the  hands  of  the  author,  that  he  rarely 
finds  it  necessary  to  employ  clasps. 

The  size  of  the  plate  which  he  employs  for  a  single  in- 
cisor, or  for  two  or  three  front  teeth,  is  indicated  by  the  dotted 
line  on  the  plaster  model,  as  represented  in  Fig.  224.  The 
size  of  the  cavity  may  also  be  seen  by  the  wax  placed  in  the 
centre  of  the  circle  formed  by  the  dotted  line.*  When  more 
than  two  or  three  teeth  are  required,  a  larger  plate  may  be 
employed. 

Fia.  224. 


We  have  thus  far  only  spoken  of  the  advantages  of  cavity 
plates.  We  shall  now  notice  one  or  two  of  the  disadvantages 
liable  to  result  from  their  employment.  In  the  first  place, 
the  protuberance  on  the  lower  part  of  the  plate  interferes, 
in  some  degree,  with  the  movements  of  the  tongue  and  with 
the  articulation  of  words,  but  it  becomes  less  and  less  mani- 

*  But  the  wax  here  represented  is  much  thicker  than  is  necessary.  A  cavity 
the  sixteenth  part  of  an  inch  in  depth,  will,  in  most  cases,  be  found  amply 
sufficient. 

50 


778         ARTIFICIAL   TEETH   MOUNTED    ON   A   CAVITY   PLATE. 

fest  the  longer  the  piece  is  worn,  until  ultimately  the  in- 
dividual almost  ceases  to  be  conscious  of  the  presence  of  any 
foreign  body  in  his  mouth.  But  there  is  another  and  more 
serious  objection^  and  it  is  this :  there  is  a  constant  ten- 
dency of  the  mucous  membrane,  over  the  cavity,  to  thicken 
and  come  down  into  it^  assuming  a  sort  of  hypertrophied 
condition,  and  in  some  cases  it  has  ulcerated.  We  have  not, 
however,  met  with  many  cases  in  our  own  practice  in  which 
this  has  happened.  But  this  morbid  tendency  may,  in 
nearly  every  case,  be  prevented,  by  leaving  the  piece  out  of 
the  mouth  during  the  night ;  and  the  shallower  the  cavity, 
the  less  will  be  the  liability  to  it. 


CHAPTER     SEVENTEENTH. 
PORCELAIN    BLOCK    TEETH. 

The  perfection  to  which  the  manufacture  of  block  teeth 
has  now  arrived^  renders  this  description  of  substitute  for 
the  loss  of  the  natural  organs,  in  those  cases  where  artificial 
gums  are  required,  superior,  in  many  respects,  to  single 
gum-teeth.  The  objections  that  formerly  existed  to  their 
use,  have^  one  after  another,  gradually  disappeared  before 
the  march  of  improvement,  which  has  been  as  actively  and 
as  successfully  at  work  in  this,  as  in  any  other  department 
of  science  or  art.  But  more  time,  and  close,  and  persevering 
application  are  necessary  to  obtain  a  thorough  knowledge  of 
this  than  almost  any  other  branch  of  practical  dentistry. 
The  preparation  of  the  various  materials  which  enter  into 
the  composition  of  block-teeth,  requires  at  least,  some  know- 
ledge of  chemistry,  and  to  put  these  materials  together  after 
they  have  been  prepared,  and  construct  from  them  a  den- 
tal substitute  of  this  kind,  demands  the  nicest  and  most 
skillful  manipulation.  The  slightest  error  in  the  prepara- 
tion or  mixing  of  the  materials,  Avill  often  give  a  result  en- 
tirely different  from  the  one  aimed  at,  and  teeth  made 
by  different  persons,  from  the  same  recipe,  frequently  differ 
very  widely  in  appearance,  depending  on  the  manner  in 
which  they  have  been  worked. 

In  the  description  which  we  propose  to  give  of  the  man- 
ner of  making  and  mounting  block  teeth,  we  shall  begin  by 
enumerating  the  materials  that  enter  into  their  composition. 

MATERIALS  USED  IN  MAKING  PORCELAIN  BLOCK  TEETH. 

Porcelain  teeth  are  composed  of  two  portions  ;  one  is  call- 


780        MATERIALS   FOR   MAKING   PORCELAIN   BLOCK  TEETH. 

ed  the  body  or  base,  and  the  other  the  enamel.  The  body 
is  composed  principally  of  feldspar,  silex,  and  kaolin  ; 
and  the  enamel,  of  feldspar,  with  a  small  trace  of  silex. 
With  these,  various  metallic  oxyds  or  metals,  reduced  to  a 
state  of  minute  division,  are  mixed,  for  the  purpose  of  im- 
parting the  necessary  color. 

Feldspar. — This  mineral  occurs  in  a  crystallized  state, 
in  the  form  of  oblique,  rhomboidal  prisms,  and  is  of  a  white, 
gray,  red,  brown,  green,  yellow,  or  bluish  color.  But  the 
only  kind  suited  for  use  in  the  manufacture  of  porcelain 
teeth,  is  the  pure  white.  It  consists,  according  to  Rose,  of 
silica,  66.75  ;  alumina,  17.50;  potash,  12;  lime,  1.25; 
and  oxyd  of  iron,  0.75.  It  is  found  near  Boston,  at  New 
Bedford,  Oakham,  and  West  Springfield,  Massachusetts: 
near  Philadelphia,  Pa.;  near  Wilmington,  Del.;  at  Ticon- 
deroga,  N.  Y.;  near  Baltimore,  Md.;  and  in  various  other 
places  in  the  United  States.  But  the  Wilmington,  Del.; 
Philadelphia  and  Boston  spars  are  regarded  as  the  best  va- 
rieties for  use  in  porcelain  block  teeth. 

Previously  to  use,  it  is  put  in  a  furnace  and  heated  nearly 
to  a  white  heat,  then  thrown  into  cold  water.  It  is  now 
broken  into  small  pieces;  freed  from  impurities,  and  ground 
in  a  mortar  or  mill,  to  fine  powder^  or_,  until  it  will  pass 
through  a  sieve  of  No.  9  bolting  cloth.  This  is  easily  fused 
and  when  mixed  with  silex  and  kaolin,  diffuses  itself,  in 
baking,  throughout  the  mass,  imparting  to  it  a  semitrans- 
lucent  appearance. 

Silex. — Flint,  quartz,  and  white  sand  are  the  purest  va- 
rieties of  silex,  but  for  porcelain  teeth  the  crystalline  form 
is  the  best  ;  and  this  is  found  in  great  abundance  in  various 
parts  of  the  United  States.  It  is  prepared  for  use  by  heating 
it  to  a  white  heat^  then  plunging  it  in  cold  water,  and  after- 
wards reducing  it  to  a  fine  powder  in  a  quartz  or  wedge- 
wood  mortar. 


I 


COLORING   MATERIALS.  781 

Kaolin. — This  is  the  Chinese  name  for  porcelain  clay, 
which  is  the  result  of  the  decomposition  of  mineral  feldspar, 
and  consists  of  nearly  equal  proportions  of  alumina  and  si- 
lica. It  is  of  a  yellowish  or  reddish  white  color  when  pure, 
and  is  found  at  Fairmount,  near  Philadelphia  ;  near  Wil- 
mington, Del.;  at  Montouk,  Vermont_,  on  the  Columbia 
rail  road  ;  at  Washington,  Ct.;  in  Missouri  ;  and  in  South 
Carolina. 

It  is  prepared  for  use  by  washing  in  clean  water.  After 
the  coarser  particles  have  settled  to  the  bottom  of  the  vessel, 
the  water  in  which  the  finer  ones  are  suspended  is  poured 
off  into  a  second  vessel,  where  it  is  permitted  to  remain 
until  the  whole  of  the  kaolin  has  settled  to  the  bottom. 
The  water  is  then  poured  off,  and  the  kaolin  dried  in 
the  sun. 

There  are  other  varieties  of  clay  which  have  been  found 
to  answer  quite  as  well  as  the  porcelain.  That  which 
shrinks  least,  is,  of  course,  preferable.  Two  kinds  are 
found  near  Baltimore,  which  shrink  but  very  little  in 
baking;  one  is  of  a  grayish  white,  and  the  other,  of  a  blu- 
ish white  color.  But  less  importance  is  attached  to  clay 
as  a  constituent  of  porcelain  block  teeth,  at  this  time^  than 
formerly.    Many  dispense  with  the  use  of  it  almost  altogether. 

COLORING    MATERIALS. 

Tlic  materials  used  for  coloring  porcelain  teeth_,  are,  as  we 
have  before  stated,  metals  in  a  state  of  minute  division  or, 
metallic  oxyds  mixed  in  certain  proportions  with  the  body 
or  enamel,  or  both.  The  following  are  the  principal  metals 
and  oxyds  employed  for  this  purpose : 

Metals  and  Oxyds  used.  Color  given. 

Gold  in  fillings  and  its  oxyds,  .         Bright  rose  red. 
Platina  sponge  or  fillings,         .         .     Grayish  blue. 

Purple  powder  of  cassius,     .  . "        Rose  purple. 
Oxyd  of  titanium,             .          .  .     Bright  yellow. 


782  COLORING  MATERIALS. 

Oxyd  of  uranium,         .         .         .  Grreenish  yellow. 

Oxyd  of  manganese,         .         .         .  Purple. 

Oxyd  of  silver,     ....  Lemon  yellow. 

Oxyd  of  cobalt,         ....  Bright  blue. 

Of  the  above,  the  oxyds  of  gold,  platina  sponge  and  tita- 
nium are  the  most  important.  With  these,  nearly  every 
color  and  tint  required  may  be  obtained. 

Metallic  Gold. — This  may  be  prepared  for  use  by  grind- 
ing gold  in  filings,  or  in  leaf  with  a  small  quantity  of  spar 
in  a  mortar  or  on  a  slab  until  reduced  to  a  fine  powder  ;  or 
if  there  be  any  doubt  with  regard  to  its  purity,  the  follow- 
ing method  maybe  adopted.  Melt  in  a  crucible  with  borax, 
12  parts  pure  silver,  4  parts  gold  and  one  part  tin,  stirring, 
while  in  a  fused  state,,  until  the  gold  and  silver  are  well 
mixed  ;  it  may  then  be  poured  into  an  ingot  mould,  rolled 
very  thin  and  cut  into  small  pieces,  or  granulated  by  being 
poured  into  a  vessel  containing  water  which  is  rapidly  re- 
volving. The  whole  mass  is  now  collected,  put  into  an 
evaporating  dish  and  nitric  acid  poured  on.  When  this  has 
become  completely  saturated  with  the  silver,  it  is  poured  off 
in  a  vessel  containing  water,  and  fresh  acid  poured  on  and 
the  action  continued  until  the  whole  of  the  silver  is  decom- 
posed or  dissolved,  which  may  be  known  by  the  colorless 
appearance  of  the  fumes.  The  pure  gold  remaining  at  the 
bottom  of  the  dish  is  washed  until  completely  free  from  acid. 
A  simpler  method  of  obtaining  a  fine  powder  consists  in 
precipitating  a  solution  of  chloride  of  gold  by  means  of  pro- 
tosulphate  of  iron  ;  then  washing  the  precipitate  with  dilute 
muriatic  acid  to  remove  the  adhering  iron,  and  afterwards 
with  water  to  remove  the  acid. 

Oxyd  of  Gold. — Dissolve  gold  foil  or  pure  gold  in  aqua 
regia,  composed  of  one  jjart  nitric  and  two  parts  muriatic 
acid  ;  dilute  the  solution  with  water  and  precipitate  the  gold 
with  aqua  ammonia,  using  the  precaution  not  to  add  more 


COLORING  MATERIALS.  783 

than  is  required,*  then  pour  off  the  acid  and  wash  the 
precipitate  with  warm  water  until  it  is  completely  freed 
from  salt  of  ammonia;  after  which,  it  may  be  dried  over 
a  gentle  fire. 

Platina  Sponge. — This  is  obtained  by  dissolving  the  metal 
in  fillings  in  a  mixture  of  one  part  nitric  and  two  parts 
muriatic  acid,  diluting  the  solution  with  an  equal  quantity 
of  water  and  precipitating  the  platina  by  means  of  aqua  am- 
monia, which  is  afterwards  separated  in  the  form  of  a  yel- 
low powder,  by  filtering  through  paper.  This,  on  being 
exposed  to  a  red  heat,  will  leave  fine  platinum  in  the  form 
of  a  dark  lead-colored  spongy  mass. 

Purple  Poiuder  of  Cassius. — R  No.  1.  This  is  a  com- 
pound of  gold  and  tin,  and  according  to  Thenard,  is  made 
by  dissolving  the  gold  in  a  mixture  of  one  part  muriatic 
and  two  parts  nitric  acid,  diluting  the  solution  with  water, 
filtering  and  diluting  again  with  a  very  large  quantity  of 
water.  The  tin  is  dissolved  in  aqua  regia,  composed  of  one 
part  nitric  acid,  two  parts  water,  and  to  every  pint,  add  one 
hundred  and  thirty  grains  of  muriate  of  soda.  The  tin 
should  be  pure  and  added  to  the  acid  in  small  pieces,  wait- 
ing for  each  one  to  be  dissolved  before  putting  in  another. 
The  operation  should  be  conducted  in  a  cool  place,  and  very 
slowly.  After  it  is  finished,  the  solution  is  filtered,  and 
about  one  hundred  times  its  volume  of  water  added  to  it. 

The  solution  of  gold  is  now  placed  in  a  glass  vessel,  and 
that  of  the  tin  added  to  it — drop  by  drop — stirring  con- 
stantly with  a  glass  rod,  until  the  liquid  assumes  the  color 
of  port  wine.  When  the  precipitate  settles  to  the  bottom 
of  the  vessel,  the  liquid  is  poured  oft',  and  the  precipitate 
washed  and  dried. 

Purple   Powder   of    Cassius. — R    No.   2.      Pure   silver, 

*  If  an  excess  of  ammonia  is  added,  the  precipitate  will  be  rediesolved  and  a  ful- 
minating compound  formed. 


784  COLORING   MATERIALS. 

432  grs.;*  gold  foil,  48  grs.;  pure  tin  foil,  36  grs.  Put  the 
gold  and  silver  in  a  crucible^  cover  well  with  horax,  and  melt ; 
then  add  the  tin,  and  pour  the  melted  mass  immediately  in 
cold  water,  to  granulate  it.  Collect  the  particles,  and  melt 
and  granulate  again,  repeating  the  operation  two  or  three 
times,  covering  the  metal  each  time  with  borax,  and  raising 
the  heat  no  higher  than  is  necessary  to  melt  it,  as  the  tin 
would  be  burnt  out  with  a  greater  heat.  The  object  of 
melting  so  often,  is  to  mix  the  metals  thoroughly  together  ; 
and  the  vessel  in  which  it  is  granulated  should  be  wood  or 
porcelain. 

Put  the  metal  in  a  porcelain  evaporating  dish,  and  add 
nitric  acid  to  decompose  the  silver,  which  operation  will  be 
expedited  by  a  gentle  heat.  Should  the  acid  cease  to  act 
before  the  silver  is  all  dissolved — which  may  be  known  by 
the  fumes  ceasing  to  rise — it  should  be  poured  oif,  and  fresh 
acid  added.  Wlicn  the  silver  is  all  decomposed,  pour  ofi' 
the  acid,  leaving  the  precipitate  behind.  Put  this,  which 
is  the  purple  cassius,  in  a  deep  glass  vessel  ;  fill  it  with 
water,  and  stir  witli  a  glass  rod.  Let  it  stand  until  the 
sediment  subsides  ;  then  pour  off  the  water,  and  add  fresh, 

*  Pure  silver  may  be  obtained  in  the  following  manner:  Dissolve  the  silver  in  a 
mixture  of  one  part  nitric  acid  and  tliix'c  paits  water,  in  a  glass  or  porcelain  ves- 
sel. The  action  of  the  acid  will  be  expedited  by  applying  a  gentle  heat.  If  there 
should  not  be  acid  enough  to  decompose  the  .silver,  it  may  be  poured  ofifwhen  the 
effervescence  stops,_and  the  fumes  cease  to  rise,  and  fresh  acid  added.  When  the 
silver  is  all  dissolved,  filter  the  solution  through  a  glass  funnel,  into  a  glass  or  por- 
celain vessel.  Then  add  a- large  quantity  of  water.  Now,  add  to  the  solution  of 
silver,  a  strong  solution  of  chloride  of  soda,  (common  salt,)  in  hot  water,  until  it 
ceases  to  cause  a  white  precipitate,  which  is  the  chloride  of  silver. 

When  this  precipitate  ha.s  subsided  to  the  bottom  of  the  vessel,  pour  off  the  liquid 
and  add  fresh  water,  repeating  this  operation  until  the  water  comes  off  pure,  and 
free  from  metallic  taste.  Now,  dr}'  the  chloride.  This  done,  put  into  a  crucible 
two  and  a  half  times  its  weight  of  carbonate  of  potassa,  (salt  of  tartar,  or  pearl- 
ash.)  Plact' the  crucible  in  a  strong  fire ;  and  when  the  carbonate  of  potassa  is 
melted,  add  the  chloride  of  silver  in  small  portions,  using  the  precaution  not  to  add 
too  much  at  a  time,  as,  in  this  case,  an  effervescence  would  take  place,  which 
would  cause  it  to  be  ejected  into  the  fire.  When  the  chloride  is  all  reduced,  the 
silver  will  be  found  in  the  bottom  of  the  crucible  in  a  pure  state.  The  heat  should 
be  great  enough  to  melt  the  silver,  so  that  it  may  run  down  to  the  bottom  of  the 
crucible.  After  cooling  sufficientl}'  to  solidify  the  silver,  the  melted  mass  on  top 
may  be  poured  off,  and  the  silver  taken  out  and  cleaned. 


COLORING  MATERIALS.  785 

repeating  the  washing  uibil  the  water  is  free  from  metallic 
taste.  The  purple  cassius  is  now  dried  in  an  evaporating 
dish,  and  kept  dry  for  use. 

The  nitric  acid  poured  off  contains  the  silver,  and  may 
be  obtained  in  a  metallic  state,  in  the  manner  as  described 
for  obtaining  pure  silver. 

Oxyd  of  Titanium. — This  is  found  in  nature — sometimes 
nearly  pure,  and  sometimes  combined  with  oxyd  of  iron. 
The  principal  ores  are  sphene,  common  and  foliated  ;  rutile, 
iserine,  menachanite,  and  octapedrife,  or  pyramidal  tita- 
nium ore.     The  purest  varieties  should  be  selected  for  use. 

Oxyd  of  Uranium. — The  prepared  article,  as  sold  by 
chemists,  contains  about  two  parts  of  the  metal,  and  three 
of  the  oxyd,  in  the  form  of  a  yellow  powder.  It  is  gene- 
rally used  as  found  in  nature. 

Oxyd  of  3fanganese. — This  occurs  abundantly  in  nature, 
and  is  obtained  from  chemists  iu  the  form  of  a  coarse  black 
powder. 

Oxyd  of  Silver. — Tli';  is  made  by  dissolving  silver  in 
nitric  acid,  and  precipitating  the  silver  by  adding  potash  or 
soda  to  the  solution.  The  liquid  is  then  poured  off — the 
precipitate  washed  with  water  and  dried. 

Oxyd  of  Cobalt. — The  preparation  of  this  oxyd  is  attended 
with  much  trouble,  and  as  the  quantity  used  in  the  manu- 
facture of  teeth  is  so  small,  we  do  not  deem  it  necessary  to 
describe  the  process_,  and  especially  as  it  can  be  obtained 
from  most  chemists.  There  is  a  ])reparation  made  from  the 
oxyd,  superior  to  the  oxyd  itselHor  coloring  teeth.  It  is 
called,  in  popular  language,  the  ashes  of  cobalt,  and  is 
made  by  wrapping  the  oxyd  in  blue  English  laid  paper, 
and  burning  it  in  a  closed  crucible.  This  gives  a  more  de- 
sirable tint  to  the  enamel  of  a  tooth  than  the  oxyd. 


786  COMPOSITION   AND   PREPARATION   OF   BODY. 


COMPOSITION   AND   PREPARATION   OP   BODY. 

We  shall  give  but  four  recipes  for  body,  either  of  which, 
if  properly  worked,  will  produce  good  teeth. 

No.   1.  No.  3. 

Delaware  spar,  12  oz.*  Delaware  spar,        12  oz. 

Silex,  2  ''  5  dwts.  Silex,  3  " 

Kaolin,  7^"  Kaolin,  18  dwts.    ^ 

Titanium,         18  to  36  grs.  Titanium,       18  to  36  grs. 

No.   2.  No.  4. 

Delaware  spar,  12  oz.  Delaware  spar,         16  oz. 

Silex,  3  ''  8  dwts.  Silex,  3^  '' 

Kaolin,  8  "  Kaolin,  ^  •• 

Baltimore  clay,  4  "  Titanium,         20  to  60  grs. 

Titanium,        18  to  36  grs. 

Put  the  titanium  in  a  large  mortar  and  grind  until  it  is 
reduced  to  an  impalpable  powder,  then  add  the  silex  and 
grind  from  one  to  three  hours,  or  until  there  shall  be  no 
perceptible  grit ;  now  add  the  kaolin  and  grind  from  thirty 
minutes  to  an  hour  and  a  half,  and  lastly  add  the  spar, 
little  by  little,  and  grind  from  forty  to  sixty  minutes.  All 
the  ingredients  should  not  be  ground  equally  fine,  as  the 
translucency  of  the  teeth  is  increased  by  having  some  coarser 
than  the  rest. 

The  materials  may  be  ground  dry  or  in  water.  If  the 
latter  method  is  adopted,  a  sufiicient  quantity  of  water 
should,  from  time  to  time,  be  added,  to  form  a  batter  of  the 
consistence  of  cream,  and  after  the  grinding  is  completed  it 
may  be  poured  on  a  clean  slab  made  of  plaster  of  paris,  and 
as  soon  as  it  acquires  the  consistence  of  stiff  dough,  it  may 
be  removed,  and  after  having  been  beat  for  twenty  or  thirty 

*  All  the  ingredients  should  be  weighed  with  Troj  weights. 


I 


I 


COMPOSITION   AND   PREPARATION    OF   ENAMEL. 


787 


minutes  on  a  marble  slab,  put  away  in  an  earthen  jar  for 
use.  When  the  ingredients  are  ground  dry,  they  may  be 
mixed,  a  small  quantity  at  a  time,  as  they  are  needed  for 
use.  Many  prefer  having  the  materials  ground  in  this 
way. 

COMPOSITION   AND   PREPARATION   OP   ENAMEL. 

Any  of  the  following  recipes  will  produce  a  good  enamel, 
and  among  them  will  be  found  nearly  every  shade  of  color 
and  tint  required,  but  others  may  be  obtained,  if  desired, 
by  adding  other  coloring  ingredients.  The  author,  how- 
ever, has  not  found  it  necessary  to  do  so.  The  oxyds  should 
be  reduced  to  an  impalpable  powder,  and  thoroughly  incor- 
porated with  the  enamel  paste. 


Grayish  Blue  Enamel. 


Yellow  Enamel. 


No.  1. 


Boston  spar, 
Platina  sponge, 
Oxyd  of  gold. 


No.  2. 


2  oz. 


2  oz. 
i  gi'- 


Boston  spar, 
Platina  sponge^ 
Oxyd  of  gold. 

No.  3. 

Boston  spar,  2  oz. 

Platina  sponge,     f  gr. 
Oxyd  of  gold,        ^  gr. 


No.   1. 

Boston  spar. 
Titanium, 
Platina  sponge, 
Oxyd  of  gold. 

No.  2. 

Boston  spar. 
Titanium, 
Platina  sponge, 
Oxyd  of  gold. 

No.  3. 

Boston  spar. 
Titanium, 
Platina  sponge, 
Oxyd  of  gold. 


2  oz. 

10  grs. 

i  gr. 

i  gr. 


2  oz. 

]4  grs. 

igr. 

i  gr. 


2  oz. 

16  grs. 

h  gr. 

^gr. 


T88 


COMPOSITION   AN^D   PREPARATION   OF   ENAMEL. 


I 


No.  4. 


No.  4. 


Spar,                        2  oz. 

Spar, 

2  oz. 

Flux,                    24  grs. 

Flux, 

20  grs. 

Platina  sponge,     ^  gr. 

Titanium^ 

10  grs.* 

No.  1  of  the  blue  and  No.  3  of  the  yellow,  will  produce 
an  enamel  that  will  suit  a  larger  proportion  of  the  cases  than 
almost  any  other.  The  coloring  ingredients  should  he  first 
ground  very  fine  with  five  or  six  dwts.  of  the  spar,  when 
the  remainder  of  the  spar  should  be  added  a  little  at  a  time, 
and  ground  from  thirty  to  forty  minutes. 

The  coloring  ingredients  for  the  following  recipes  are  pre- 
pared by  being  ground  very  fine  with  spar. 

Platina  Coloring.  Titanium  Coloring. 

Platina  sponge,  1  dwt.  12  grs.  Titanium,  7  dwts.  12  grs. 

Boston  spar,  1  oz.    Boston  spar,      1  oz. 


Grayish  Blue  Enamel. 

No.  1. 
Boston  spar,  2  oz. 

Platina  coloring, 
Titanium  coloring, 


Tellmo  Enamel. 
No.  1. 
Bost<"»n  spar. 


12  grs.  Titanium  coloring, 
2    "     Platina  coloring. 


2  oz. 

1  dwt. 

2  srrs. 


No.  2. 

Boston  spar, 
Platina  coloring, 
Titanium  coloring. 


No.  2. 

2  oz.     Boston  spar, 

1  dwt.  Titanium  coloring, 

2^  grs,  Platina  coloring. 


2  oz. 
2  dwts. 
2A  orrs. 


No.  3. 

Boston  spar,  2  oz. 

Platina  col' ng,  1  dwt.  12  grs. 
3  2rs. 


Titanium  coloring. 


No.  3. 

Boston  spar, 
Titanium  coloring, 
Platina  coloring. 


2  oz. 

3  dwts. 
3  grs. 


*  The  proportion  of  coloring  inpfredienta  may  be  increased  or  diminished,  accord- 
ing to  the  color  wanted.  A  sufBcient  variety  of  shades  for  moat  cases,  will  be  ob- 
tained from  the  recipes  which  we  have  giren. 


COMPOSITION    AND    IMlKI'AUATrON    OV    KNAMKI,.  '789 

Tlie  roregoing  iivc  ground  sopiiratoly  until  tlic  i-oloiing  in- 
grodit'utH  are  tliorouglily  incoriKualoil  with  tlu'  spur.  Wy 
grimling  tlio  K[)ar  too  fine,  tlic  liti'-likci  a)>|)('araiic(i  and 
beauty  of  tlie  enamel  will  he  dcslroycd. 

Tlie  numner  ol' piepaiing  the  eoloring  ingre<lit'nls  Coi-  flio 
following  recipe,  is  as  1'oIIowh  : 

Platina  Colorimj. — Platiiia  sponge,  1  dwt.,  12  grs.; 
Boston  spar,  1  oz.  2.^  dwts.,  mix  and  grind  veiy  fine. 

(luld  Mixture. — Dissolve  eight  grains,  pure  gold,  in  (tqna 
icgia,  then  stir  in  twelve  and  a  hall'  dwts.  very  finely  ground 
spar.  When  nearly  dry,  Ibrni  it  into  a  ball,  and  fuse  it  on 
a  slide  in  a  iurnace.  Alter  which,  })ulverize  it  coarsely  and 
kee})  it  for  use. 

O'rai/ish  Blue  Enamel.  Yellow  EnmneL 

No.  1.  No.  1. 

Boston  s[tar,  2  oz.  Boslon  sj)ar,     2  o/. 

Prepared  platina  Titanium,        U)  grs. 

sponge,  2  dwts.       IMcjtared  platina 

Gold  Mixture,  4  grs.  sponge,  <S  grs. 

Gold  mixture,  2  dwis.  10  grs. 

For  the  yellow  enamel,  first  grind  the  tilaniiim  and 
platina  sponge  very  fine,  then  add  the  gold  mixture,  which 
should  also  be  ground  fine  ;  after  which  add  the  spar  and 
grind  until  tlie  coloring  ingredients  are  thoroughly  incor- 
porated wilh  it.* 

Gum  enamel  is  made;  with  a  frit,  (!(d()r(!(l  either  with  me- 
tallic gold  in  a  state  of  minute  division,  its  oxyd,  or  purple 
cassius  and  spar.  Jiesidcs  the  coloring  ingredients,  gum 
enamel  frit  is  composed  of  a  flu.x,  made  especially  for  the 
purpose,  and  spar.  We  shall  first  descrihe  (hf  him  oner  of 
making  the  flux. 

*  In  iill  butoneof  tlio  fori^xoinK  r<;cijn'H,  Ut<»  HohIoii  npiir  Ih  incntioiH'd,  and  for 
the  rcaHon  that  it  Cuhih  at  a  Bornewliat  lower  tcni|»iTulur<'  than  Un-  Dilawuii-,  which 
the  author  ha8  dcHii^iialcd  aH  th(f  kind  to  hi'  UHcd  in  the  rc(.i|icH  Cur  tlii'  hw\y.  Thi-ri' 
are  two  or  thr<M!  kindnol  Hpar  ohtaincil  near  I'liiliidilphia,  very  Hitnilarlo  thi-  Dela- 
ware, Knaujula  inudu  from  auy  uf  the  rucipuH  here  given  uxmy  be  u«ed  on  auy  of 
the  bod  i  CM. 


790  COMPOSITION   AND   PREPARATION   OF   ENAMEL. 

Flux. — Silex,  4  oz.;  glass  of  borax,*  1  oz.;  sal  tartar, 
1  oz,;  mix  and  grind  to  an  impalpable  powder  ;  then  pack 
it  in  the  bottom  of  a  clean,  light-colored  crucible.  Cover  ') 
this  with  a  piece  of  slide,  previously  fitted  into  the  top,  and 
lute  with  kaolin  or  clay.  Now  place  the  crucible  in  a  strong 
anthracite  fire,  free  from  smoke^  and  let  it  remain  until  the 
the  mass  is  completely  fused,  which  will  require  from  an 
hour  and  a  half  to  two  hours  and  a  half,  depending  on  the 
strength  of  the  fire. 

When  cold,  break  the  crucible,  and  remove  every  parti- 
cle from  the  flux  ;  which,  if  it  has  not  become  stained  by 
coloring  matter  in  the  crucible,  will  be  a  transparent  glass. 
If  any  portion  has  become  discolored,  this  should  be  broken 
off,  and  the  remainder  pulverized,  and  kept  dry  for  use.f 

Gum  Frit,  No.  1. — Metallic  gold  in  a  state  of  minute  di- 
vision or  its  oxyd,  16  grs.;  flux,  175  grs.;  spar,  700  grs. 

Put  the  above  in  a  mortar,  and  grind  until  it  is  reduced 
to  an  impalpable  powder,  which  will  require  from  five  to 
eight  hours  constant  labor,  then  pack  it  in  a  light  colored 
crucible  washed  inside  with  a  thin  batter  of  very  finely  pul- 
verized silex,  and  outside  with  kaolin  ;  now  fit  to  the  top  of 
the  crucible  a  piece  of  slab  and  lute  it  down  with  kaolin, 
place  it  near  a  fire,  and  when  dry  put  it  in  a  strong  anthra- 
cite fire,  free  from  smoke,  in  a  furnace  where  it  must  remain 
until  it  is  fused,  which  will  require  from  an  hour  and  a  half 
to  two  hours,  then  remove  it  and  when  cold,  break  the  cru- 
cible and  grind  off  the  silex.  This  done,  it  may  be  broken 
and  ground  until  it  will  pass  through  a  sieve.  No.  9  bolting 
cloth. 

Gum  Frit,  No.  2. — Purple  cassius,  8  grs.;  fiux,  175  grs.; 
spar,  700  grs.     Reduce  the  purple  cassius,  in  a  mortar,    to 


*  Glass  of  borax  is  made  by  putting  the  pure  crystals  in  a  clean  light-colored 
crucible ;  then  place  the  crucible  in  a  fire  free  from  smoke,  and  let  it  remain  until 
the  borax  assumes  a  transparent  glassy  appearance.  Now  pour  it  on  a  clean  marble 
slab,  and  when  cold,  pulverize  and  keep  in  a  well  stopped  bottle  to  prevent  it  from 
absorbing  the  moisture  from  the  air. 

t  Flint  glass  is  sometimes  used  for  a  flux. 


I 


I 


COMPOSITION   AND   PREPARATION  OF  ENAMEL.  791 

an  impalpable  powder,  then  add  the  flux,  little  by  little, 
grinding  each  time,  to  a  ver}^  fine  powder.  Now  add  the 
spar,  a  small  quantity  at  a  time,  reducing  each  parcel  to  a 
very  fine  powder,  and  the  whole  to  the  utmost  degree  of  fine- 
ness. To  do  this  properly,  will  require  from  six  to  eight 
hours  constant  labor,  and  unless  the  mixing  and  levigation 
are  conducted  in  a  right  manner  the  resulting  color  will  be 
unsatisfactory. 

After  having  reduced  the  mass  to  the  proper  fineness,  se- 
lect the  whitest  sand  crucible  that  can  be  obtained,  fit  a 
piece  of  slide  to  the  top,  as  a  cover.  Now  cover  the  inter- 
nal surface  of  the  crucible  with  a  paste  made  from  finely  pul- 
verized quartz,  putting  it  on  with  the  finger.  This  done, 
pack  the  frit  into  it  in  a  dry  state,  then  put  the  cover  on  and 
lute  tight  with  kaolin.  Now  put  an  external  coating  of 
quartz  on  the  crucible  ;  then  bury  it  in  a  strong  anthracite 
fire,  and  let  it  remain  until  the  contents  are  perfectly  fused. 
The  time  required  for  this,  will  vary  according  to  the  size 
of  the  crucible  and  the  strensjth  of  the  fire.  When  the  frit 
is  completely  fused,  the  crucible  may  be  removed  from  the 
fire,  and  when  cold,  break  it  and  remove  every  particle  of 
foreign  matter.  Then  pulverize  until  it  will  pass  through 
a  sieve  of  No.  9  bolting  cloth.* 

Gum  Enamel. 

No.  1  No.  2. 

Frit,  No.  1,  3  dwts.  Frit,  No.  2,       3  dwts. 

Spar,  9  to  12  dwts.  Spar,  3  to  18  dwts. 

The  spar  should  be  coarsely  ground,  in  order  to  give  the 
gum  a  granular  appearance,  and  the  quantity  of  frit  may 
be  increased  or  diminished  until  the  right  color  is  produced. 
It  should,  therefore,  be  tried  on  test  pieces  of  body  before 
being  applied  to  a  practical  piece.     Frit   made  at   difierent 

*  For  a  number  of  the  forgoing  recipes,  the  author  is  indebted  to  the  liberality 
of  several  professional  friends,  whose  skill  in  this  department  of  dentistry  is  unsur- 


792  ANTAGONIZING   MODEL  FOR  BLOCK   TEETH. 

times  will  produce  different  results.  The  gum  enamel,  No, 
2,  is  designed  particularly  for  body  No.  4,  and  enamel  No. 
4,  but  may  be  used  on  any  of  the  other  bodies,  and  with  any 
of  the  other  enamels. 

Having  enumerated  the  materials  which  enter  into  the 
composition  of  the  body,  enamel  and  gum,  and  described  the 
manner  of  preparing  and  mixing  them  for  use,  we  shall 
proceed  to  notice  the  method  of  making  and  mounting  the 
teeth.  We  shall  begin  by  describing  the  manner  of  obtain- 
ing an  antagonizing  model  for  a  set  for  the  upper  jaw,  and 
of  making  the  matrix  for  moulding  the  body  preparatory  to 
carving  the  teeth. 

ANTAGONIZING  MODEL  FOR  AN  UPPER  SET  OF  BLOCK  TEETH. 

The  method  of  procedure  for  obtaining  an  antagonizing 
model  for  block  teeth  is  similar  to  the  one  described  in  a  pre- 
ceding chapter,  and  one  made  for  this  j^urpose  will  answer 
for  any  other  kind  of  dental  substitute.  A  rim  of  softened 
yellow  wax,  about  half  an  inch  thick,  is  placed  upon  the 
lower  or  convex  surface  of  the  plate.  This  is  then  adjusted 
in  the  mouth,  and  the  patient  requested  to  close  his  teeth  in 
the  wax  with  sufficient  force  to  make  an  indentation  in  it,  an 
eighth  of  an  inch  deep.  The  piece  is  now  taken  from  the 
mouth,  the  wax  carefully  removed,  and  another  rim,  corres- 
ponding in  width  to  the  length  required  for  the  artificial 
teeth,  fitted  to  the  plate,  which  is  again  placed  in  the  mouth, 
and  the  patient  requested  to  close  his  teeth  gently  upon  the 
wax.  If  all  do  not  touch  the  lower  edge  of  it  at  the  same  in- 
stant, it  should  be  trimmed  off  until  they  do.  The  exterior 
surface  of  the  wax  should  be  also  cut  away  until  it  describes 
the  proper  arch  for  the  buccal  and  labial  surfaces  of  the  arti- 
ficial teeth  and  restores  to  the  lips  and  cheeks  their  natural 
contour.  This  done,  the  patient  is  again  requested  to  close 
his  teeth  upon  the  edge  of  the  wax  with  just  sufficient  force 
to  leave  the  imprint  of  each  tooth. 


'.> 


MANNER   OF   MAKING   A   MATRIX.  793 

The  plate  is  now  taken  from  tlie  moutli,  laid  aside,  and 
the  wax  first  employed  placed  upon  a  piece  of  pasteboard  or 
paper,  with  the  side  in  which  the  teeth  were  partially  im- 
bedded, upwards.  The  exposed  portion  and  indentations 
are  smeared  with  oil.  A  batter  of  plaster  of  paris  is  next 
poured  on  it,  filling  the  impressions  made  by  the  teeth,  and 
running  down  an  inch  and  a  half  behind  it  on  the  paper, 
and  the  whole  raised  to  a  level  of  half  an  inch  above  the 
wax.  As  soon  as  the  plaster  has  consolidated  sufficiently, 
the  edges  should  be  trimmed  off,  and  a  crucial  groove,  or 
two  or  three  conical  depressions  made  in  the  lower  surface 
behind  the  wax,  which  may  now  be  softened  and  carefully 
removed,  using  the  precaution  not  to  break  the  ends  of  the 
teeth.  This  done,  the  model  is  placed  upon  a  piece  of  paper 
with  the  teeth  upwards,  and  the  rim  of  wax  last  used,  still 
attached  to  the  plate,  is  adjusted  to  the  teeth  in  such  a 
manner  that  tlie  point  of  each  shall  enter  the  imprint  made 
by  the  natural  organs  the  last  time  they  were  closed  against 
it.  The  upper  surface  of  the  plate  and  model  having  been 
previously  smeared  with  oil,  batter  of  plaster  of  paris  is 
poured  on  the  two  for  the  formation  of  the  other  part  of  the 
antagonizer.  When  the  plaster  has  congealed  sufficiently, 
the  two  pieces  are  separated,  and  the  plate  and  wax  care- 
fully removed,  to  be  used  for  the  formation  of  the  matrix, 
in  which  to  mould  the  body  preparatory  to  carving, 

MANNER  OP  MAKING  A  MATRIX  FOR  MOULDING  THE  BODY  PRE- 
PARATORY TO  CARVING  THE  TEETH. 

Having  obtained  an  antagonizing  model,  the  inside  of  the 
wax  is  cut  away  until  it  presents  the  appearance  represented 
in  Fig.  225.  It  is  left  a  little  thicker  than  the  artificial 
teeth  will  be,  allowance  having  been  made  for  shrinkage  in 
the  baking  and  also  for  the  removal  of  a  small  portion  in 
carving,  especially  from  the  part  from  which  the  incisors 
and  cuspids  will  be  formed.  The  plate  and  wax  are  now 
51 


794 


MANNER    OF   MAKING   A   MATRIX. 


returned  to  the  upper  part  of  the  antagonizing  model,  and 
the  exposed  surfaces  of  both  smeared  with  oil ;  then  a  thick 


FiQ.    225. 


Fig.   226. 


Fie.  227.  batter  of  plaster  of  paris  is 

poured  on  in  the  manner 
as  described  for  making  the 
upper  part  of  the  antago- 
nizing model.  As  soon  as 
the  plaster  has  hardened 
sufficiently,  the  edges  are 
trimmed  to  tlie  wax,  tlie  ma- 
trix separated,  and  the  low- 
er part  of  the  antagonizing 
model  applied.  Vertical 
lines  are  now  made  across 
tlie  wax,  to  indicate  tlie 
width  required  for  the  arti- 
ficial teeth.  See  Fig.  226. 
This  done,  the  antagonizing 
part  of  the  model  is  remov- 
;  ed  the  lower  part  of  the  ma- 
trix applied  and  the  lines 
in  the  wax  continued  across 
the  edge  of  it,  to  serve  as  a 
guide  for  marking  tlie 
widtli  of  the  teeth  preparatory  to  carving.     See  Fig.  227. 


MANNER   OF   MAKING   A   MATRIX.  Y95 

The  two  parts  are  again  separated  and  the  plaster  cut  away 
from  the  surface  in  contact  with  the  wax  of  the  lower  piece, 
forming  an  open  space  between  it  and  the  edge  of  the  wax, 
equal  in  width  to  about  one-tenth  or  twelfth  of  that  of  the 
latter.  The  matrix  will  now  present  the  apj^earance,  when 
the  two  parts  are  put  together^  represented  in  Fig.  227. 
The  object  of  this  space  is  to  provide  for  the  shrinkage  in 
the  length  of  the  teeth,  consequently  its  width  should  cor- 
respond with  the  amount  which  the  j)aste  for  the  body 
shrinks  in  baking.  Body  made  from  the  first  recipe  shrinks 
a  little  more  than  one  made  from  the  second,  and  one  from 
this  a  little  more  than  one  from  the  third. 

Plaving  proceeded  thus  far,  the  wax  may  be  removed,  and 
a  coat  of  varnish  applied  to  each  part  of  the  matrix.  The 
appearance  of  the  two  pieces  when  put  together  is  shown  in 
Fig.  228.  The  antagonizing  model  and  matrix^  as  will  be 
perceived  from  the  foregoing  description^  consist  of  but  three 
pieces.  By  this  simj)le  contrivance,  the  artist  will  be 
able  to  adapt  the  coronal  extremities  of  the  artificial  teeth 
to  the  opposing  natural  organs,  with  the  most  perfect  accu- 
racy, as  he  can  at  any  moment  remove  the  lower  part  of  the 
matrix  and  aj^ply  the  antagonizing  part  of  the  model  to  his 
work. 

Some  dentists  are  in  the  habit  of  first  carving  the  teeth 
in  wax^  and  making  the  matrix  to  consist  of  five  pieces  ; 
one  upper  and  one  lower,  and  three  for  the  sides  and  front. 
In  this  the  teeth  are  roughly  moulded.  But  they  after- 
wards require  trimming,  and  it  is  quite  as  easy,  and  much 
more  expeditious  to  carve  them  from  the  porcelain  paste  in 
the  first  instance.  One  who  is  skilled  in  the  business^  can 
carve  a  double  set,  after  having  moulded  the  body  in  ma- 
trices like  the  one  we  have  described,  in  an  hour  and  a  half 
or  two  hours. 


796  MOULDING   AND   CARVING. 


MOULDING    AND     CARVING. 

A  block  for  an  entire  set  of  teetli  for  the  upper  or  lower 
jaw,  shrinks  so  much  in  baking,  as  not  only  to  destroy  its 
adaptation  to  the  plate,  but  also  the  proper  relationship  of 
the  artificial  to  the  natural  teeth.  But  this  difficulty 
may  be  measureably  obviated  by  making  three  blocks^  a 
central  for  the  incisors  and  cuspids,  and  two  lateral  for  the 
bicuspids  and  molars.  Some  are  in  the  habit  of  making 
four,  but  with  a  good  body,  three  are  all  that  are  required. 
The  central  should  be  made  first. 

If  the  composition  for  the  body  has  been  ground  in  a  dry 
state,  as  much  as  may  be  needed  at  any  one  time,  may  be 
put  in  a  mortar,  and  a  sufficient  quantity  of  clean  water 
poured  on  to  form  it  into  a  thick  batter,  stirring  it  until 
thoroughly  mixed.  It  should  then  be  poured  on  a  slab  of 
plaster  of  paris,  as  before  directed,  for  the  absorption  of  the 
surplus  water,  and  afterwards  beat  for  a  few  minutes  on  a 
marble  or  porphyry  slab.  Thus  prepared,  the  matrix,  after 
having  been  well  oiled,  may  be  filled  with  the  paste,  patting 
it  with  the  fingers  for  a  minute  or  two,  for  the  purpose  of 
driving  out  the  confined  air. 

As  soon  as  the  water  haTs  evaporated  sufficiently,  the 
paste  protruding  from  the  matrix,  may  be  trimmed  off",  the 
lower  part  of  the  mould  loosened,  but  kept  in  place,  and 
the  width  of  the  incisors  and  cuspidati  marked  with  the 
point  of  a  small  carving  knife  upon  the  body,  the  notches 
across  the  edge  of  the  lower  part  of  the  mould  serving  as  a 
guide  for  this  part  of  the  operation.  The  teeth,  however, 
should  be  a  little  wider  than  the  spaces  between  the  notches 
or  marks  on  the  matrix,  so  that  each  cuspid  will  occupy 
one-third  of  the  space  indicated  for  the  first  bicuspid,  this 
being  about  the  amount  which  the  "front  or  central  block 
will  shrink  in  baking. 

After  marking  the  width,  the  outline  of  the  labial  sur- 
faces may  be  traced,  and  the  carving  commenced,  copying 


CRUCING,  OR   BISCUITING.  797 

nature  as  closely  as  possible.  The  teeth  may  be  separated 
by  drawing  a  thread,  held  in  a  small  bow,  between  them. 
The  antagonizing  part  of  the  mould  may  be  applied  from 
time  to  time,  to  enable  the  artist  to  determine  the  amount 
required  to  be  taken  from  the  palatine  surfaces.  In  con- 
ducting this  part  of  the  work,  a  great  deal  of  tact  is  re- 
quired, as  the  slightest  touch,  or  accident,  will  break  the 
block  ;  the  body,  in  this  state,  being  exceedingly  tender  and 
brittle.  If  it  should,  at  any  time,  become  too  dry,  it  may 
be  moistened  by  applying  a  little  water  with  the  point  of 
the  carving-knife,  or  a  small  camel' s-hair  pencil.  The 
portion  back  of  the  cuspid  teeth,  is,  of  course,  cut  off,  and 
may  be  put  with  the  body  not  used. 

Having  completed  the  front  block,  it  may  be  loosened 
from  the  plate,  by  gently  tapping  the  part  of  the  matrix 
to  which  it  is  attached,  and  then  removed  and  placed  upon 
pulverized  silex,  on  a  slide.  This  done,  the  matrix  may  be 
refilled  with  paste,  and  the  side  blocks  carved,  making  the 
first  bicuspids  to  occupy  about  one-third  of  the  spaces  marked 
on  the  matrix  for  the  cuspids,  and  these,  in  like  manner,  are 
removed  and  placed  near  the  central  block,  on  the  slide. 

The  only  instruments  required  for  carving  are  two  or 
three  small  knives  shaped  something  like  the  blade  of  a 
thumb  lancet,  but  more  pointed  and  smaller, 

CRUCING,    OR    BISCUITING. 

As  soon  as  the  blocks  have  become  thoroughly  dry,  they 
may  be  put  in  the  muffle  of  a  furnace,  previously  heated, 
and  subjected  to  a  bright  red  heat_,  which  will  be  sufficient 
to  agglutinate  the  particles  of  the  composition,  but  not  to 
vitrify  the  body.  This  is  called  crucing,  or  hiscmtmr/,  and 
is  sometimes  done  in  a  charcoal  fire,  in  a  small  open  fur- 
nace, the  blocks,  in  this  case,  having  been  first  placed  on  a 
little  pulverized  silex,  in  a  crucible.  Bat  it  is  most  readily 
effected  in  a  mufile  furnace. 

If  the  carving  has  been  roughly  executed,  the  shape  of 


798 


ENAMELING. 


the  teeth  may  be  easily  altered,  and  any  rough  places  re- 
moved after  the  blocks  have  been  cooled.  They  can  now  be 
handled  without  incurring  much  risk  of  breaking. 

INSERTION    OF    THE    PLATINA    PINS. 

^i<J-  229.  Several  methods  of  attaching 

blocks  to  a  plate  have  been 
adopted,  but  the  one  which 
affords  the  greatest  permanence 
and  stability  to  the  work,  con- 
sists in  soldering  a  band  to  pla- 
tina  pins  inserted  in  the  blocks 
behind  the  teeth,  and  afterwards 
to  the  plate.  These  pins  are 
sometimes  put  in  before  the  blocks  are  cruced,  but  as  the 
teeth  are  so  exceedingly  frail  at  this  time,  it  is  better  to 
defer  it  until  they  have  been  subjected  to  this  process.  The 
manner  of  inserting  them  is  very  simple,  and  consists  in 
drilling  two  small  holes  in  the  block  behind  each  tooth,  im- 
mersing the  block  suddenly  in  water,  and  inserting  a  pin, 
flattened  at  the  end,  in  each  hole.  The  space  around  them 
should  be  filled  with  the  composition  of  the  body  mixed 
with  water  to  about  the  consistence  of  thin  cream.  This 
may  be  applied  with  a  small  carael's-hair  pencil,  or  with 
the  point  of  the  carving-knife.  The  pins  should  pass  from 
half  to  two-thirds  of  the  way  through  the  block,  and  be 
about  an  eighth  of  an  inch  apart,  one  placed  above  the 
other.  The  blocks  for  a  set  for  the  upper  jaw  are  represented 
in  Fig.  229. 

ENAMELING. 


The  enamel,  when  applied,  should  be  of  the  consistence 
of  cream,  and  if  the  teeth  are  to  have  a  uniform  color,  it 
will  only  be  necessary  to  use  two  kinds,  one  for  the  teeth 
But  in   the   majority  of  cases   three 


and  one  for  the  gum 


FIRING   AND   BAKING.  799 

kinds  are  needed^  a  grayish  blue  for  the  lower  part  of  the 
crowns,  yellowish  near  the  gum,  and  rose  red  for  the  gum. 
The  teeth  should  be  well  cleaned  before  the  enamel  is  put 
on.  The  gum-color  should  be  applied  first,  then  the  yellow, 
and  lastly  the  grayish  blue,  and  the  best  method  of  putting 
it  on  is  with  a  small  camel' s-hair  brush.  It  should  be  of 
uniform  thickness  and  come  down  a  little  below  the  ends  of 
the  incisors  and  cuspids,  so  as  to  give  them  the  translucency 
peculiar  to  the  natural  teeth.  A  thin  coating  may  also  be 
applied  to  the  grinding  surfaces  of  the  molars  and  bicuspids. 
It  is  not  required  on  the  palatine  surfaces.  In  applying  the 
gum-color,  care  should  be  taken  to  prevent  it  from  coming 
down  on  the  teeth,  and  at  the  same  time  to  have  it  form  a 
well  defined  edge.  The  grayish  blue  should  overlap  the 
yellow,  blending  the  two  tints  in  such  a  manner  as  to  render 
it  impossible  to  tell  where  the  one  begins  or  the  other  termi- 
nates. 

The  enamel  having  been  applied,  the  blocks  are  carefully 
placed  on  a  bed  of  silex  on  the  slide,  and  when  perfectly 
dry,  put  in  the  furnace. 

FIRING    AND    BAKING. 

This  is  usually  done  in  a  small  mufiie  furnace,  like  the 
one  represented  in  Fig.  230,  though  some  dentists  liave  a 
furnace  constructed  somewhat  differently.  A  clear,  strong 
fire,  made  of  the  hardest  anthracite  coal,  is  required  for 
baking  the  blocks.  It  is  first  kindled  with  charcoal_,  and, 
after  this  has  become  thoroughly  ignited,  the  anthracite  is 
added^  a  little  at  a  time,  until  the  furnace  is  full.  As  the 
muffle,  at  the  high  temperature  required  for  fusing  the 
blocks,  and  under  the  weight  of  the  coal  above,  is  liable  to 
sink  down  in  the  centre,  it  should  be  supported  with  a  rester 
underneath,  made  of  fire-brick  clay.  The  anthracite  coal, 
after  it  has  settled  and  become  thoroughly  ignited,  should 
be  two  or  three  inches  deep  on  the  top  of  the  muffle,  and  the 
opening  through  which  the  fuel  is  introduced^  closed. 


800 


FIRING   AND   BAKING. 


Thus  heated,  the  slide  may  be  carefully  introduced  into 
the  muffle  of  the  furnace,  the  opening  closed,  and  the  door 
luted  with  fire  clay.  Some  dentists  use  a  test  piece,  consist- 
ing of  a  small  piece  of  the  paste  used  for  the  body,  with  a 
little  enamel  on  one  side  of  it,  fixed  to  the  end  of  a  platina 

Fig.  230. 


wire,  projecting  from  the  inner  extremity  of  a  plug  made  of 
fire  clay,  and  fitting  a  hole  in  the  centre  of  the  door  of  the 
muffle.  By  withdrawing  this,  the  progress  of  the  baking 
can  be  ascertained.  But  the  use  of  it  is  not  necessary, 
especially  to  one  experienced  in  this  business.  Most  persons 
are  in  the  habit  of  opening  the  door  of  the  muffle,  and 
partially  withdrawing  the  slide,  as  it  is  thought  the  blocks 
have  baked  sufficiently.  When  the  enamel  has  become  fused, 
and  run  smoothly  over  the  surfaces  to  which  it  was  applied, 


Fig.  230.  A  muflfle  furnace ;  a  Collar  for  the  smoke-pipe  ;  6  the  opening  through 
which  the  fuel  is  introduced  ;  c  The  muflle  door  ;  d  The  ash-pit  door  ;  e  Stopper 
for  the  opening  b ;  /  Stopper  for  closing  the  opening  to  the  muffle;  g  Stopper  for 
the  opening  to  the  ash-pit ;  h  muffle ;  i  Stopper  with  platina  wire  and  test ;  j  Slide. 


FITTING  AND   ATTACniNQ   BLOCKS  TO  THE  PLATE.  801 

the  process  has  heen  carried  far  enough.  The  upper  stopper 
may  now  he  removed,  the  draft  of  air  cut  off  from  the  fire 
by  closing  the  door  to  the  ash-pit,  and  the  furnace  permitted 
to  cool.  When  the  combustion  has  ceased,  and  the  temper- 
ature become  so  much  reduced  as  to  permit  of  the  introduc- 
tion of  the  hand  into  the  muffle,  the  slide  may  be  removed. 
If  it  is  talcen  out  before  the  furnace  has  cooled,  the  teeth 
will  be  very  liable  to  crack  under  the  blow-pipe, 

PITTING    AND    ATTACHING    THE   BLOCKS   TO   THE   PLATE. 

The  adaptation  of  the  blocks  to  the  base  is,  often,  more 
or  less  impaired  by  the  shrinkage  which  takes  place  in 
baking,  and  as  it  is  important  that  they  should  fit  with  the 
nicest  accuracy,  it  frequently  becomes  necessary  to  grind 
them  before  attaching  them  to  the  plate.  The  blocks  should 
also  be  fitted  to  each  other  so  perfectly,  by  grinding,  as  to 
render  the  line  of  union  scarcely  perceptible. 

But  having  accomj)lished  this  part  of  the  operation,  and 
antagonized  the  blocks  properly  with  the  opposing  teeth, 
they  are  retained  in  plac  >  with  a  rim  of  softened  beeswax, 
applied  to  the  labial  and  buccal  surfaces,  and  outer  edge  of 
the  base;  the  plate  behind  .the  blocks  are  then  smeared 
with  oil,  and  a  batter  of  plaster  of  paris  poured  on,  filling  the 
arch,  and  covering  the  coronal  extremities  of  the  teeth. 
When  this  has  hardened,  the. wax  may  be  removed  and  the 
blocks  taken  from  and  applied  to  the  base  without  disturb- 
ing their  proper  relationship.  A  strip  of  gold,  a  little  thin- 
ner than  that  used  for  the  base,  about  an  eighth  of  an  inch 
wide,  and  long  enough  to  extend  from  the  posterior  pala- 
tine angle  of  the  hindmost  block  on  one  side,  around  to  the 
same  point  on  the  other.  This  should  be  slightly  grooved, 
and  accurately  fitted  to  the  plate  along  the  outer  edge  of 
the  blocks,  with  the  grooved  side  towards  them.  This  done, 
the  plate  may  be  marked,  with  a  sharp  pointed  steel  instru- 
ment, on  the  outside  of  this  rim.     The  plaster  and  blocks 


802  FITTIXa   AND    ATTACHING   BLOCKS    TO    THE    PLATE. 

may  now  be  removed,  the  strip  of  gold  confined  in  its  place 
by  wrapijing  tlie  plate  witli  fine  iron  wire.  It  is  then  sol- 
dered at  three  or  four  different  points,  and  afterwards  all 
the  way  around  to  the  j^late. 

The  blocks  may  now  be  separated  from  the  plaster,  ad- 
justed to  the  plate,  and  held  in  place  partly  by  the  rim  just 
soldered  to  it,  and  partly  by  a  rim  of  wax  placed  against 
their  buccal  and  labial  surfaces.  The  next  thing  to  be  done, 
is  to  apply  a  strip  of  gold  from  a  quarter  to  three-eighths  of 
an  inch  in  width,  and  of  the  thickness  of  the  plate,  to  the 
palatine  surface  of  each  block.  A  pattern  for  each  of  these 
linings  is  first  made  by  applying  sheet  lead  or  tin  to  the 
block,  which  as  it  is  pressed  against  it,  is  perforated  by  the 
platina  pins.  It  is  then  trimmed  to  the  proper  size,  and 
fitted  accurately  to  the  base.  This  is  placed  upon  gold 
plate,  and  a  piece  of  the  same  size  and  shape  cut  from  it. 
The  perforations  in  the  pattern  indicate  the  points  at  which 
the  holes  are  to  be  punched  through  the  plate.  When  these 
are  made,  it  is  applied  and  fitted  tightly  to  the  block,  and 
the  platina  pins  bent  a  little  to  one  side  to  hold  it  firmly  in 
place.  These  are  then  cut  or  filed  off  nearly  up  to  the 
plate,  the  block  returned  to  its  place  on  the  base,  to  which 
the  lining  should  be  made  to  fit  with  the  most  perfect  accu- 
curacy,  as  well,  also,  as  to  the  end  of  the  lining  of  the  ad- 
joining block. 

All  the  linings  having  been  applied  and  the  blocks  ad- 
justed to  the  base,  a  rim  of  wax  may  be  put  on  the  inside 
to  keep  the  teeth  in  place  while  the  outer  rim  is  removed. 
The  piece  may  now  be  put  in  plaster  or  a  mixture  of  equal 
parts  of  plaster  and  fine  sand,  or  coarsely  pulverized  quartz 
or  asbestos;  this  done,  a  mixture  of  finely  ground  borax 
and  water  is  applied  along  the  line  of  connection  between 
the  linings  of  the  three  blocks,  the  linings  and  plate  and 
the  posterior  extremity  of  the  lining  of  each  block  and  the 
outer  rim  of  gold,  as  well  as  around  each  platina  pin  ;  to 
all  of  which  places  solder  is  applied.  The  work  is  now 
ready  for  soldering,  and  as  this  process  has  been  described 


\ 


FITTING   AND    ATTACHING   BLOCKS   TO   THE   PLATE. 


803 


in  another  place,  it  is  not  necessary  to  repeat  what  has 
already  been  said  npon  the  subject.  The  process  of  finish- 
ing is  also  the  same  as  that  for  a  set  of  single  teeth  mounted 
upon  plate. 


Fio.  231. 


Fig.  332. 


The  above  cuts  represent  a  front  and  palatine  view  of  a 
set  of  block  teeth  mounted  on  a  metallic  base  for  the  upper 
jaw.  The  rim  on  the  outside  around  the  upper  edge  of  the 
block  is  not  always  put  on,  but  it  adds  very  much  to  the 
strength  and  beauty  of  the  piece,  and  also  to  its  cleanliness, 
if  fitted  up  tightly,  as  it  always  should  be,  to  the  blocks. 

There  are  two  other  methods  of  attaching  blocks  to  a 
plate.  One  consists  in  making  vertical  holes  through  the 
blocks,  one  for  each  tooth  after  they  have  been  cruced.  A 
gold  pin  is  passed  through  each  tooth  and  riveted  on  the 
upper  side  of  the  plate ;  or,  first  soldered  to  the  plate,  and 
riveted  on  the  grinding  surfaces  of  the  molars  and  bicus- 
pids and  the  palatine  surfaces  of  the  incisors  and  cuspidati. 
The  other  method  consists  in  soldering  pins  to  the  plate 
which  pass  half  or  two-thirds  of  the  way  through  the  teeth. 
But,  according  to  the  observations  and  experience  of  the  au- 
thor, the  first  is  the  most  substantial  method,  and,  there- 
fore, we  have  not  thought  it  necessary  to  give  a  detailed 
description  of  either  of  the  others. 

In  making  a  double  set  of  block  teeth,  the  two  matrices 
are  made  one  with  the  upper  and  the  other  with  the  lower 
parts  of  the  antagonizing  model,  made  with  two  rims  of 
wax,  one  representing  the  upper  and  the  other  the  lower 


804  FITTING   AND    ATTACHING   BLOCKS   TO   THE   TEETH. 

teeth.  The  lines  marked  on  the  wax  to  indicate  the  width 
of  the  teeth  are  so  arranged  as  to  represent  the  relationship 
which  the  upper  and  lower  teeth  sustain  to  each  other  when 
the  jaws  are  closed. 

Note. — The  originals  of  nearly  all  the  illustrations  in  the 
foregoing  chapter  were  made  for  the  author  b}^  Dr.  M.  D. 
French,  formerly  a  student  of  his,  and  for  which  courtesy 
he  takes  pleasure  in  acknowledging  his  indebtedness. 


CHAPTER     EIGHTEENTH. 

SINGLE  PORCELAIN   TEETH  MOUNTED  ON  A  METALLIC 
BASE,  WITH  CONTINUOUS  ARTIFICIAL  GUMS. 

Since  the  publication  of  the  fifth  edition  of  this  work,,  the 
above  method  of  mounting  artificial  teeth  has  been  adopted 
extensively  by  the  profession  in  most  of  the  principal  cities 
in  the  United  States,  and  to  some  extent  in  Europe.  It  was 
introduced  almost  simultaneously  by  Drs.  John  Allen  and 
W.  H.  Hunter,  both  of  Cincinnati,  Ohio,  in  1851,  eacb 
claiming  priority  of  discovery.  The  former,  however,  se- 
cured to  himself  the  exclusive  benefit  of  it  by  letters  patent. 
But  the  idea  of  uniting  porcelain  teeth  to  a  metallic  base 
by  means  of  a  fusible  silicious  composition,  originated  in 
France,  where  the  method  has,  to  some  extent,  been  prac- 
ticed since  1820.  The  composition  employed  there,  how- 
ever, judging  from  the  specimens  which  the  author  has  in 
his  possession,  cannot  be  used  in  connection  with  porcelain 
teeth  containing  as  large  a  proportion  of  feldspar  as  those 
manufactured  in  this  country.  The  credit  of  the  discovery 
of  such  a  composition  belongs  to  Drs.  Hunter  and  Allen. 

It  was  thought  when  this  method  of  mounting  artificial 
teeth  was  first  adopted,  that  the  springing  of  the  plate  in  the 
act  of  mastication  would  cause  the  gum  to  crack  and  scale 
off,  and  while  this  does  occur  in  a  large  proportion  of  the  cases, 
the  injury  is  usually  easily  repaired  by  replacing  the  loss  with 
fresh  composition  and  fusing  it  to  the  fractured  edges  of  the 
remaining  portions,  and  to  the  plate.  For  beauty  of  ap- 
pearance and  cleanliness,  it  is  unsurpassed  by  any  other  des- 
cription of  dental  substitute. 

By  uniting  the  teeth  to  each  other,  near  their  base,  and 


806  SINGLE   PORCELAIN   TEETH   ON   METALLIC   BASE. 

to  the  plate,  the  cleanliness  of  the  substitute  is  more  per- 
fectly secured,  as  all  the  openings  beneath  and  around  them 
are  completely  closed,  excluding  the  secretions  of  the  mouth 
and  particles  of  alimentary  substances,  which,  by  finding 
lodgment  in  these  places,  soon  become  putrid,  and  impart 
to  the  breath  an  offensive  odor.  In  this  respect,  they  are 
superior  to  the  most  perfectly  mounted  block  teeth,  and  the 
labor  of  putting  up  a  set  of  the  former  can  be  performed  in 
half  the  time  required  for  making  and  mounting  a  set  of  the 
latter.  The  gum  is  continuous,  without  seam  or  crack, 
from  one  side  to  the  other  ;  and  a  person  who  can  mount 
single  teeth  well^  can  acquire  a  knowledge  of  this  method, 
with  proper  instruction,  in  two  or  three  days. 

Two  compounds  are  employed  :  the  first,  is  termed  the 
hase  or  hody,  as  this  constitutes  the  principal  jDart  of  the 
cement  and  is  used  for  filling  in  between  the  teeth  and  build- 
ing up  the  gum  on  the  plate,  the  other  is  termed  gum- 
enamel.  The  materials  employed  by  Dr.  Hunter,  in  the 
composition  of  his  compound  are,  silex,  fused  spar,  calcined 
borax,  caustic  potash  and  asbestos.  The  silex  and  spar 
should  be  of  the  clearest  and  best  quality,  and  ground  very 
fine.  The  asbestos  sliould  be  freed  from  talc  and  other 
foreign  substances,  and  reduced  to  a  fine  powder.  He  gives 
the  following  formulas  : 

'^JBase. — Take  flux*,  1  oz.;  asbestos  2  oz.;  grind  togeth- 
er very  finely,  completely  intermixing.  Add  granulated 
body,t  IJ  oz.;  and  mix  with  a  spatula  to  prevent  grinding 
the  granules  of  body  any  finer. 

*  The  flux  used  by  Dr.  Hunter  is  composed  of  silex,  8oz.;  calcined  borax,  4  oz.; 
caustic  potash,  1  oz.  The  potassa  is  first  ground  fine  in  a  wedgewood  mortar,  and 
the  other  materials  gradually  added  until  they  are  thoroughly  mixed.  "Line  a 
Hessian  crucible  (as  white  as  can  be  got)  with  pure  kaolin,  fill  with  the  mass,  and 
lute  on  a  cover  of  a  piece  of  fire-cla}'  slab,  with  the  same.  Expose  to  a  clear  strong 
fire  in  a  furnace  with  coak  fuel,  for  about  half  an  hour  or  until  it  is  fused  into  a 
transparent  glass,  which  should  be  clear  and  free  from  stain  of  any  kind.  This  is 
broken  and  ground  until  it  will  pass  through  a  bolting  sieve. 

■j-This  may  be  made  of  hard  porcelain,  fine  China  or  wedgewood,  but  Dr.  Hunter 
uses  spar,  3  oz.;  silex,  13^^  oz,;  kaolin,  }4  oz-;  completely  fused.  "Break  and  grind 
so  that  it  will  pass  through  a  wire  sieve  No.  60,  and  again  sift  off  the  fine  particles 
which  pass  through  No.  10  bolting  cloth,"  which  leaves  it  in  grains  about  the  size 
of  the  finest  gunpowder. 


SINGLE   PORCELAIN    TEETH   ON   METALLIC   BASE.  807 

^'■Gum  Enamels. — No.  1.  Flux  1  oz,;  fused  spar,  1  oz.; 
English  rose,  40  grains.  Grind  the  English  rose  extreme- 
ly fine  in  a  mortar,  and  gradually  add  tlie  flux  and  then 
the  fused  spar,  grinding  until  the  ingredients  are  thoroughly 
incorporated.  Cut  down  a  large  Hessian  crucible  so  that 
it  will  slide  into  the  muffle  of  a  furnace,  line  with  silex  and 
kaolin  each  one  part,  put  in  the  material  and  draw  up  the 
heat  on  it  in  a  mufiie  to  the  ^omt  oi  vitrification,  not  fusion, 
and  withdraw  from  the  muffle.  .The  result  will  be  a  red 
cake  of  enamel  which  will  easily  leave  the  crucible, 
which,  after  removing  any  adhering  kaolin,  is  to  be  broken 
down  and  ground  tolerably  fine.  It  may  now  be  tested 
and  then  (if  of  too  strong  a  color)  tempered  by  the  addi- 
tion of  covering.  This  is  the  gum  which  flows  at  the  low- 
est heat,  and  is  never  used  when  it  is  expected  to  solder. 

"No.  2.  Flux^  1  oz.;  fused  spar,  2  oz.;  English  rose,  60 
grains.  Treat  the  same  as  No.  1.  This  is  a  gum  inter- 
mediate, and  is  used  upon  platina  plates. 

"No,  3.  Flux,  1  oz.;  fused  spar,  3  oz.;  English  rose,  80 
grains.  Treat  as  the  above.  The  gum  is  used  in  making 
pieces  intended  to  be  soldered  on,  either  in  full  arches 
or  in  the  sections  known  as  block  ivork.  It  is  not  necessary 
to  grind  very  fine  in  preparing  the  above  formulas  for  ap- 
plication. 

^^ Covering. — What  is  termed  covering,  is  the  same  as 
the  formulas  for  gums,  minus  the  English  rose,  and  is  made 
without  any  coloring  whatever  when  it  is  used  for  temper- 
ing the  above  gums  which  are  too  highly  colored,  and 
which  may  be  done  by  adding,  according  to  circumstances, 
from  1  part  of  covering  to  2  of  gum,  3  of  covering  to  1  of 
gum,  thus  procuring  the  desired  shade.  When  it  is  to  be 
used  for  covering  the  base  prior  to  applying  the  gum,  it 
may  be  colored  with  titanium  using  from  two  to  five  grains 
to  the  ounce. 

"2nvestie7it. — Take  two   measures  of  white  quartz  sand, 
mix  with  one  measure  of  plaster  of  paris,  mixing  with  just 


808  SINGLE   PORCELAIN   TEETH   ON   METALLIC  BASE. 

enough  water  to  make  the  mass  plastic,  and  apply  quickly. 
The  slab  on  which  the  piece  is  set  should  be  saturated  with 
water  to  keep  the  material  from  setting  too  soon,  and  that 
it  may  unite  with  it. 

"3Iemoranda. — In  preparing  material,  always  grind  dry, 
and  the  most  scrupulous  cleanliness  should  attend  all  of  the 
manipulations.  In  all  cases  where  heat  is  applied  to  an 
article  in  this  system,  it  should  be  raised  gradually  from 
the  bottom  of  the  muffle,  and  never  run  into  a  heat.  Where 
it  is  desired  to  lengthen  any  of  the  teeth,  either  incisors  or 
masticators,  or  to  mend  a  broken  tooth,  it  may  be  done 
with  covering,  properly  colored  with  platina,  cobalt  or  ti- 
tanium. 

"In  preparing  a  piece  of  work,  wash  it  with  great  care, 
using  a  stiff  brush  and  pulverized  pumice-stone.  Bake  over 
a  slow  fire  to  expel  all  moisture,  and  wash  again^  when  it  will 
be  ready  for  any  new  application  of  the  enamel.  Absorp- 
tion, occurring  after  a  case  has  been  some  time  worn,  by 
allowing  the  jaws  to  close  nearer,  causes  the  lower  jaw  to 
come  forward  and  drive  the  upper  set  out  of  the  mouth. 
By  putting  the  covering  on  the  grinding  surface  of  the  back 
teeth  in  sufficient  quantities  to  make  up  the  desired  length, 
the  coaptation  of  the  denture  will  be  restored,  and  with  it 
the  original  usefulness. 

"Any  alloy,  containing  copper  or  silver,  should  not  be 
used  for  solder  or  plate,  if  it  is  intended  to  fuse  a  gum  over 
the  lingual  side  of  the  teeth^  as  it  will  surely  stain  the  gum. 
Simple  platina  backs  alone,  do  not  possess  the  requisite  stiff- 
ness, and  should  always  be  covered  on  platina  with  the 
enamel,  and  on  gold  with  another  gold  back.  In  backing 
the  teeth,  lap  the  backs  or  neatly  join  them  up  as  far  as 
the  lower  pin,  in  the  tooth,  and  higher  if  admissible,  and 
in  soldering  be  sure  to  have  the  joint  so  made  perfectly 
soldered. ' ' 

The  composition  originally  employed  by  Dr.  Allen,  for 
the  case  consists  of  silex,  2  oz.;  flint  gloss,  1  oz.;  borax,  1 
oz.;  wedgewood,  1^  oz.;  asbestos,    2   drachms  ;  feldsj)ar,    2 


SINGLE  PORCELAIN  TEETH   ON   METALLIC  BASE.  809 

drachms ;  kaolin,  1  draclim ;  intermixed  or  underlaid  with 
scraps  of  gold  or  platina.  For  the  enamel,  he  employs 
feldspar,  ^  oz  ;  white  glass,  1  oz  ;  and  oxyd  of  gold,  1^ 
grs.;  which  gives  it  the  gum  color.  Dr.  A.  we  believe  now 
uses  a  somewhat  different  and  better  formula. 

Since  the  publication  of  the  sixth  edition  of  this  work, 
great  improvements  have  been  made  in  the  composition  and 
preparation  both  of  the  body  and  gum  enamel,  which  are 
furnished  by  the  manufacturers  and  may  be  obtained  at 
many  of  the  dentists'  furnishing  establishments  at  a  very 
moderate  price. 

The  metals  employed  for  the  base  in  this  method  of 
mounting  artificial  teeth,  are,  platina  or  pure  palladium. 
The  common  commercial  article  of  palladium  is  not  pure  ; 
it  contains  about  fifty  per  cent,  silver.  Platina,  alloyed 
with  pure  gold  may  also  be  used. 

In  mounting  a  set  of  artificial  teeth  with  the  continuous 
gum^  a  plate  is  first  struck  up  with  the  outer  edge  either 
turned  up  or  a  rim  soldered  on  in  the  manner  as  described 
in  a  preceding  chapter.  The  teeth  are  then  selected,  ar- 
ranged on  wax  to  the  plate^  the  backings  or  linings  put  on, 
and  united  to  the  plate  as  in  the  ordinary  way  of  mounting. 
The  piece  is  now  tried  in  the  mouth  and  if  the  teeth  were 
not  antagonized  proj)erly  on  the  model,  each  one  is  adjusted 
by  pressing  it  slightly  outward  or  inward  as  the  case  may 
require  to  give  it  an  equal  bearing  upon  the  opposing  teeth. 
This  readjusting  of  the  teeth  may  not  often  be  necessary, 
but  it  is  a  precaution  which  it  is  well  to  observe,  lest  the 
mouth  may  not  have  been  closed  naturally  at  the  time  the 
antagonizing  model  was  made. 

Having  proceeded  thus  far,  the  silicious  compound,  which 
flows  at  a  lower  heat  than  is  required  to  fuse  the  teeth,  is 
placed  upon  the  plate  and  teeth  in  such  a  manner  as  to  fill 
up  all  the  interstices  between  and  around  their  base,  and 
then  carved  to  represent  the  gums.  This  done,  the  cement 
is  thoroughly  dried^  and  the  piece  put  on  a  slide  with  the 
coronal  ends  of  the  teeth  downwards  and  imbedded  to  the 
52 


810  SINGLE   PORCELAIN   TEETH   ON   METALLIC   BASE. 

depth  of  about  a  quarter  of  an  inch  in  a  thick  batter  of 
plaster  and  asbestos,  filling,  after  this  has  set,  the  upper 
and  concave  surface  of  the  plate  with  the  same  composition. 

After  this  has  become  dry,  the  slide  is  placed  in  a  heated 
mufiie  and  subjected  to  a  heat  sufficiently  high  to  fuse  the 
compound — say  twenty-two  hundred  and  fifty  degrees.  It 
is  then  withdrawn,  cooled,  and  if  the  baking  has  caused  no 
defects,  gum-enamel  is  j^ut  on  as  in  block -work,  and  when 
dry,  the  piece  is  put  back  in  the  furnace  and  this  last  compo- 
sition fused  as  before.  If  defects  occur  in  the  first  baking, 
they  are  repaired  by  filling  up  the  cracks  with  more  of  the 
body  or  base,  previous  to  putting  on  the  gum-enamel.  The 
enamel  is  sometimes  put  on  before  the  first  baking.  If  in 
baking,  the  composition  leaves  the  plate,  the  piece  may  be 
put  in  the  furnace  a  second  time,  but  with  the  plate  down- 
wards, when,  as  soon  as  the  compound  fuses,  it  will  at  once 
come  back  to  and  unite  Avith  the  plate.  Great  care  is  neces- 
sary in  baking.  If  the  piece  is  subjected  to  too  much  or  to 
too  little  heat,  it  will  be  more  or  less  defective^  and  the  ex- 
act amount  required  can  only  be  determined  by  one  who  has 
had  some  experience  in  this  j)art  of  the  operation. 

In  mounting  teeth  with  the  continuous  gum  it  is  necessary 
to  rim  the  plate  or  to  turn  up  the  outer  edge,  to  give  thick- 
ness to  the  cement  where  it  terminates  upon  the  base.  This 
stifiens  the  plate^,  and  diminishes  its  liability  to  spring  or 
the  compound  to  crack  and  scale  ofi".  Additional  stiflhess 
may  also  be  given  to  it,  while  at  the  same  time  the  entire 
piece  will  be  greatly  strengthened,  by  soldering  a  band,  ex- 
tending all  the  way  round,  to  the  inside  of  the  backings  of 
the  teeth,  previously  to  putting  on  the  compound,  which 
may  be  thinly  covered  with  it  and  gum-enamel,  thus  com- 
pletely concealing  it  from  view. 

In  constructing  a  dental  substitute  for  the  lower  jaw,  upon 
this  principle,  the  plate,  instead  of  being  rimmed  or  turned 
up,  should  have  a  half  round  wire  soldered  to  the  upper 
surface  of  the  edge  all  the  way  round,  both  on  the  buccal 
and  lingual  sides. 


CHAPTER    NINETEENTH. 

CHEOPLASTIC    METHOD    OF    MOUNTING    ARTIFICIAL 

TEETH. 

Among  the  peculiar  advantages  claimed  for  the  Cheoplastic 
over  the  other  methods  now  practiced,  of  mounting  artifi- 
cial teeth,  are  perfect  accuracy  of  adaptation  of  the  hase  to 
the  plaster  model — metallic  castings  not  being  used  in  this 
process — and  greater  practical  usefulness  and  dura.bility. 
It  can  also  be  done  in  less  time,  and  the  material  used  for 
the  base  in  this  process  is  less  expensive — it  being  an  alloy, 
the  precise  composition  of  wliich  we  have  never  taken  pains 
to  ascertain,  as  it  can  be  obtained  from  the  manufacturer, 
and  at  most  of  the  dental  depots,  of  a  better  quality,  we 
presume,  and  at  a  lower  price  than  it  can  be  made  for  in 
small  quantities.  It  is,  however,  composed  principally  of 
tin,  silver  and  bismuth,  with  a  small  trace  of  antimony.* 
The  alloy  imparts  no  taste  whatever  to  the  mouth,  and  its 
purity,  so  far  as  its  capability  of  resisting  the  action  of  the 
secretions  of  the  buccal  cavity  is  concerned,  is  said  to  be 
fully  equal  to  that  of  eighteen  carat  gold.  The  lustre  of  it, 
after  being  worn  some  weeks,  becomes  slightly  dimmed,  but 
is  immediately  restored  by  placing  it  in  a  strong  solution  of 
caustic  potash.  This  is  the  only  change  we  have  ever  ob- 
served, and  we  have  seen  it  after  having  been  worn  in  the 
mouth  nearly  two  years. 

This  method  of  mounting  teeth  has  only  been  practiced 

*A8  the  right  to  manufacture  the  alloy,  as  well  as  the  entire  process,  has  been 
secured  to  the  iavector.  Dr.  A.  A.  Blandy,  by  letters  patent,  the  exact  composition 
may  be  seen  in  the  specification  which  accompanied  his  application  for  the  patent. 


812 


CHEOPLASTIC   METHOD    OF   MOUNTIXG   TEETH. 


since  the  fall  of  1855,  that  is,  with  the  above  mentioned 
alloy,  and  it  was  not  made  known  to  the  profession  generally 
until  February,  1857.  Since  this  time,  it  has  been  adopted 
and  practiced  by  nearly  three  hundred  dentists,  and  among 
the  number  are  many  of  the  most  skillful  and  respectable 
practitioners  in  the  United  States.  Thus  far  we  believe  it 
has  fully  realized  the  expectations  of  its  most  zealous  advo- 
cates, and  judging  from  the  testimony  of  others,  as  well  as 
from  results  which  have  come  under  our  own  observation, 
the  use  of  it  seems  likely,  in  a  very  short  time,  to  become 
general. 

Fia.  233. 


In  mounting  artificial  teeth  by  the  Cheoplastic  process,  the 
first  thing  to  be  attended  to  is,  to  take  an  impression  of  the 
mouth  either  with  wax  or  plaster  of  paris.  If  it  is  desired 
to  have  a  central  chamber  or  cavity  in  the  base^  with  a  view 
to  make  it  adhere  more  firmly  to  the  parts  against  which  it 
is  to  rest,  one  of  the  right  size,  depth  and  shape,  is  cut  at 
the  proper  place  in  tlie  impression,  which,  if  of  plaster, 
is  varnished^  then  placed  on  a  piece  of  pasteboard  or  paper, 


CHEOPLASTIC   METHOD   OF   MOUNTING  TEETH.  813 

and  surrounded  with  soft  putty,  or  any  plastic  substance,  as 
dough  or  clay.  A  sheet  iron  or  tin  ring  is  then  placed  over 
it,  (the  lower  edge  slightly  embedded  in  the  putty,)  large 
enough  to  leave  a  space  of  about  a  quarter  of  an  inch  all 
around  between  the  two,  except  at  the  back  part,  where  it 
should  be  an  inch  and  a  quarter  at  least,  for  the  formation 
of  an  articulating  surface  for  the  two  parts  of  the  matrix, 
which  may  also  be  used  for  the  antagonizing  model.  The 
ring  should  be  about  an  inch  or  an  inch  and  a  quarter  in 
depth.     See  Fig.  233. 

The  model  is  made  of  equal  parts,  by  weight,  of  plaster 
of  paris  and  finely  pulverized  spar,  mixed  with  pure  water 
until  of  the  consistence  of  thin  batter.*  The  impression  and 
surface  of  the  putty,  as  well  as  the  inside  of  the  ring  being 
oiled_,  the  mixture  is  poured  in,  stirring  it  with  a  camel's- 
hair  pencil,  until  it  is  raised  to  a  level  with  the  upper  edge 
of  the  ring.  As  soon  as  it  becomes  sufficiently  hard,  the 
ring  and  putty  are  removed,  and  the  model  carefully  sepa- 
rated from  the  impression,  which,  when  the  alveolar  border 
does  not  project,  may  be  done  without  injury  to  either. 
Half  a  dozen  or  more  models  can  often  be  taken  from  the 
same  impression.  When  the  alveolar  ridge  projects,  it  is 
sometimes  necessary  to  cut  away  the  outer  part  of  the  im- 
pression before  the  separation  can  be  effected,  but  when  this 
is  done,  care  is  necessary  to  prevent  injuring  the  model. 
Having  removed  this  from  the  impression,  the  portion  de- 
signed for  the  formation  of  the  chamber  in  the  base  may  be 
altered,  if  desired,  and  made  smoother  before  proceeding 
farther  with  the  operation. 

The  next  thing  to  be  done  is,  to  make  an  antagonizing 
model,  and  as  the  method  of  obtaining  it  for  this  process 
is  different  from  any  heretofore  given,  we  subjoin  a  brief 
description  of  it.  Two  or  three  conical  holes  are  made  in 
the  back  part  of  the  model  for  the  proper  adjustment  of  the 

*  Models  made  of  the  above  composition  are  not  as  hard  as  when  made  wholly  of 
plaster  of  paris,  but  they  are  sufficiently  solid  for  all  practical  purposes.  If  de- 
sirable, their  density  may  be  increased  by  the  use  of  Fuch's  solution  of  glass. 


814 


CHEOPLASTIC   METHOD   OF   MOU^^TING   TEETH. 


antagonizing  portion  ;  a  coating  of  varnish  is  applied  to 
every  part  except  that  which  is  to  be  covered  by  the  base  for 
the  artificial  teeth.  This  part  is  now  covered  with  a  plate 
of  thick  tin  foil,  stiffened  by  the  application  of  soft  wax  to 
the  part  within  the  arch.  This  may  be  a  quarter  or  three- 
eighths  of  an  inch  thick,  and  when  it  has  hardened,  a  rim 
of  softened  wax  is  placed  along  the  alveolar  border  and 
trimmed  down  with  a  knife  until  its  width  shall  be  a  little 
greater  than  the  length  required  for  the  artificial  teeth. 
Kemove  this  and  the  stifiened  tin  foil  plate  together,  place 
them  in  the  mouth  before  the  wax  hardens,  and  if  the  rim 
is  of  the  right  width  all  round,  request  the  patient  to  bite 
ujDon  it,  closing  the  lower  jaw  naturally,  until  a  distinct  im- 
print of  all  the  lower  teeth  is  made  in  it.     See  Fig.  234. 

Fig.  234. 


This  done,  the  wax  and  plate  are  removed  from  the  mouth, 
replaced  on  the  model,  and  the  antagonizer  made  in  the 
manner  as  described  in  a  preceding  chapter. 

The  portion  of  the  model  representing  the  alveolar  ridge 
and  roof  of  the  mouth,  after  the  antagonizing  part,  the  wax 
and  tin  foil  have  been  removed,  is  covered  with  a  fresh  plate  of 
tin.     This  is  accurately  moulded  to  the  various  depressions 


CHEOPLASTIC  METHOD   OF   MOUNTING  TEETH. 


815 


and  prominences  with  the  finger,  and  hard  rolls  of  chamois 
leather  cut  nearly  to  a  point  at  each  end — such  as  are  used 
for  shading  drawings,  called  stumps.     See  Fig.  235.     One 

Fig.  235. 


^^^^^^^^^5 


or  two  extra  strips  of  foil  maybe  placed  over  the  prominent 
parts  of  the  alveolar  ridge  to  secure  sufficient  thickness  of 
metal  at  those  points  between  the  teeth  and  gums.  A  plate 
of  sheet  wax,  rolled  to  the  thirty-fifth  or  fortieth  part  of  an 
inch  in  thickness,  is  put  over  the  tin,  covering  only  so  much 


Fia.  23fi. 


of  the  cast  as  is  to  be  occupied  by  the  metallic  base.  This 
is  carefully  and  accurately  moulded  to  the  tin  plate,  and 
then  trimmed  to  the  required  size.  See  Fig.  236,  showing 
model  and  wax  plate  separated. 


816 


CHEOPLASTIC   METHOD   OF   MOUNTING   TEETH. 


The  teeth  are  now  selected  and  arranged  upon  the  wax 
plate  on  the  model.     Grum  teeth^  either  single  or  in  blocks 
of  two  or  three  are  preferable.     As  they  are  arranged  upon 
the  cast,  the  approximal  sides  are  ground  until  the  teeth  or 
Fig.  237.  blocks  come  together  so  perfectly 

at  every  point  as  to  render  the 
line  of  union  scarcely  perceptible. 
But  the  teeth  used  in  this  process 
are  constructed  differently  from 
those  designed  for  swaged  plates. 
They  are  not  provided  with  pla- 
tina  pins  in  their  palatine  surface, 
but  have  holes  or  dove-tail  grooves 
into  which  the  metal  runs,  retaining  them  securely  to  the  base. 
A  section  of  single  and  block  teeth  designed  for  this  process 
are  represented  in  Fig.  237,  with  the  metal.  Plate  teeth  can 
be  used  and  attached  very  securely  by  bending  the  platina 
pins  until  the  ends  come  together.  As  it  is  not  a  matter  of 
any  importance  whether  the  base  of  the  teeth  fit  closely  to 
the  wax  j^late  or  not,  it  is  rarely  necessary  to  grind  them  here. 
It  is  only  done  when  the  teeth  are  too  long. 

Each  tooth  or  block,  after  having  been  properly  ground, 
is  made  fast  to  the  wax  plate  by  applying  melted  wax  to 
the  palatine  surface,  filling  the  holes  or  grooves,  which 
runs  down  and  unites  with  the  plate  beneath,  from  the 
point  of  an  instrument  constructed  for  the  purpose,  pre- 


FiQ.  238. 


viously  warmed  in  tlie  flame  of  a  spirit  lamp.  See  Fig. 
238.  The  antagonizing  part  of  the  model  is  applied  from 
time  to  time,  as  the  teeth  are  arranged,  in  order  to  insure 
accuracy  of  adjustment,  and  when  the  proper  care  is  taken, 
it  will  seldom  be  necessary,  if  the  bite  of  the  lower  teeth 
has  been  properly  taken,   to   make   any  alteration   in  the 


CHEOPLASTIC  METHOD   OF   MOUNTING  TEETH. 


817 


piece  after  it  is  put  in  tlie  mouth,  the  holes  or  grooves  of  the 
teeth  being  filled — the  amount  of  wax  applied  to  the  backs 
of  the  teeth  is  equal  to  the  amount  of  metal  required  to 
unite  them  firmly  to  the  base.  This  may  be  done  by  put- 
ting a  narrow  strip  extending  all  the  way  round  from  the 
back  tooth  on  one  side,  to  the  back  tooth  on  the  other  ;  or 
it  may  be  applied  in  small  pieces,  using  the  wax  knife 
warm  in  either  case,  to  unite  it  to  the  teeth  and  wax  plate. 
Another  strip  is  now  applied  along  the  upper  edge,  on  the 
labial  and  buccal  sides,  filling  the  groove  above  the  gum, 
and  uniting  it  with  the  wax  plate,  with  the  instrument, 
Fig.  238,  warmed  sufficiently  to  melt  the  wax.  This  strip 
is  long  enough  to  pass  behind  the  last  tooth  or  block  on 
each  side,  and  unite^  with  the  wax  applied  along  the  pala- 
tine surface.  As  metal  is  ultimately  to  take  the  place  of 
wax,  it  is  important  that  the  exact  quantity  required  be  put 
on  and  every  part  made  perfectly  smooth.  This  may  be 
done  with  the  Avax  knife,  while  warm,  and  brushes  like 


Fio.  239. 


those  represented  in  Fig.  239.  The  largest  is  designed  for 
pressing  it  down  upon  the  model,  and  the  smaller  to  smooth 
it  between  the  teeth,  and  where  the  wax  knife  cannot  be 
conveniently  employed.  The  smoothing  process  may  be  fa- 
cilitated by  throwing  the  flame  of  a  spiiit  lamp  lightly  over 
the  wax  with  a  blow-pipe  having  a  very  small  aperture  in 
the  nozzle,  slightly  melting  the  surface  and  causing  it  to 


818 


CHEOPLASTIC   PROCESS   OF   MOUNTING  TEETH. 


flow.  This  gives  it  a  beautifully  polislied  appearance.  In 
proportion  as  this  part  of  the  operation  is  neatly  and  skill- 
fully executed,  will  the  labor  of  finishing,  after  the  metal 
has  been  applied,  be  lessened. 


Fig.  240. 


An  upper  set  of  single  gum  teeth,  arranged   on  a  wax 
plate  and  model,  is  represented  in  Fig.  240.     Now,  if  there 


is  any  doubt  with  regard  to  the  proper   adjustment  of  the 
teeth,  arising  from  fear  that  the  bite  of  the  lower  teeth  in 


CHEOPLASTIC  PROCESS   OF   MOUNTING   TEETH. 


819 


the  rim  of  wax  for  the  formation  of  the  antagonizing  part 
of  the  model  was  not  natural,  the  piece  may  be  tried  in 
the  mouth  of  the  patient,  and  should  any  alteration  be 
necessary,  it  is  made  before  proceeding  further  with  the 
work. 

When  single  teeth  without  gums  are  used,  the  strip  of 
wax  in  front  and  on  each  side  is  pressed  between  each  two 
and  scalloped  out,  giving  it  a  festooned  appearance  like  the 
natural  gum^  and  leaving  points  between  the  teeth.  A  set 
thus  prepared,  is  represented  in  Fig.  241,  with  wax  made 
perfectly  smooth  between  and  around  the  teeth. 


Fio.  242. 


At  this  stage  of  the  operation,  the  work  is  placed  in  the 
ring  in  which  the  model  was  made — the  upper  edge  of  the 
former  projecting  about  a  fourth  of  an  inch  above  the  sum- 
mits of  the  teeth,  as  shown  in  Fig.  242.  The  exposed 
surfaces  of  the  model  and  inside  of  the  ring,  are  well 
oiled,  and  a  mixture  of  plaster  of  paris  and  spar,  in  the 
before  mentioned  proportions,  are  now  made  into  a  thin 
batter,  and  poured  on  gradually,  until  the  ring  is  filled, 
stirring  as  before  directed,  to  drive  out  air  bubbles,  and 


820  CHEOPLASTIC   PROCESS   OP   MOUNTING   TEETH. 

ensure  a  perfect  cast.  When  the  mixture  becomes  hard, 
the  ring  is  removed,  and  the  part  of  the  matrix  first  made 
is  tapped  lightly  with  a  small  hammer  or  mallet  until  the 
one  loosens  a  little  from  the  other,  when  the  two  may  be 
easily  separated  with  the  hands.  This  done,  cut  immedi- 
ately, while  the  composition  is  comparatively  soft,  a  groove 
or  gate  in  the  part  of  the  matrix  last  made,  which  contains 
the  teeth  and  wax  plate,  through  which  the  melted  alloy  is 

Fig.  243. 


to  be  poured^  and  two  vents,  one  on  each  side,  see  Fig.  243, 
•with  half  of  wax  plate  removed,  showing  ends  of  the  teeth. 
These  are  made  before  tlie  wax  is  removed,  to  prevent  small 
pieces  from  falling  in  the  matrix  by  the  sides  of  the  teeth. 
The  wax  is  now  removed  as  perfectly  as  possible,  as  the 
absorption  of  any  small  portions  left  in  the  matrix  has  a  ten- 
dency to  roughen  it,  and  thus  to  prevent  the  metal  from 
running  as  smoothly  as  it  would  otherwise  do.  After  re- 
moving the  wax,  each  part  of  the  matrix  is  held  over  the 
flame  of  a  tallow  candle,  until  a  slight  coating  of  carbona- 
cious  matter  forms  on  it.  The  two  parts  are  now  put  to- 
gether and  firmly  united  by  passing  an  iron  wire  two  or 
three  times  around  it  and  made  fast  by  twisting  the  ends 
tightly  where  they  meet.  The  line  of  union  is  next  luted 
with  a  mixture  of  plaster  and  spar,  leaving  the  gate  and  vents 
open.     This  is  necessary  to  prevent  the  metal  from  escap- 


CHEOPLASTIC  PROCESS  OF   MOUNTINa  TEETH.  821 

ing  when  poured,  and  even  this  does  not  always  do  it. 
Hence,  additional  means  of  security  are  sometimes  em- 
ployed. The  simplest  and  perhaps  the  best,  is  to  put  the 
matrix^  after  wiring  and  luting,  into  a  sheet  iron  or  tin 

Fig.  244. 


box,  (see  Fig.  244,)  partially  filled  with  a  thick  batter  of 
plaster  and  spar,  with  the  gate  and  vents  upwards,  thor- 
oughly imbedding  it  in  the  mixture. 

Thus  secured,  the  piece  is  put  in  a  small  gas  sheet  iron 
furnace,  stove,  kitchen  range  or  bake  oven  and  exposed  to 
a  bread  baking  heat,  say  from  300°  to  400°  Fh.,  for  from 
three  to  five  hours,  or  until  every  particle  of  moisture  is 
driven  from  it.  It  is  then  placed  in  an  upright  position, 
the  metal  melted,  and  while  at  a  temperature  sufficiently 
high  to  make  it  assume  a  light  blue  color  is  poured  quick- 
ly into  the  matrix.  If  it  does  not  bubble,  and  comes  up  into 
the  vents  freely,  the  piece  will  come  from  the  matrix  in  a  per- 
fect condition.  If  it  bubbles  it  may  be  tapped  several  times 
lightly  on  a  brick  or  some  hard  substance.  When  cold,  the 
two  parts  of  the  matrix  are  separated,  exposing  one  of  the 
surfaces  of  the  plate.  If  any  part  is  found  defective,  now  is 
the  proper  time  to  repair  it.     This  is  done  with  solders  Nos. 


822  CHEOPLASTIC   METHOD   OF  MOUNTING  TEETH. 

1  and  2,  prepared  for  the  purpose,*  muriate  of  zinc  being  used 
as  a  flux.f  This  latter  is  applied  to  the  defective  part  on 
the  end  of  a  small  piece  of  wood,  previously  dipped  in  the 
liquid  muriate.  A  sufficient  quantity  of  solder  is  now  placed 
on  the  defective  part  and  a  small  jet  of  flame  from  a  spirit 
lamp  is  thrown  lightly  on  it  with  a  blow-pipe  having  a  very 
small  hole  in  the  nozzle.  As  soon  as  the  solder  flows  freely 
and  smoothly  the  projection  of  the  flame  is  immediately 
discontinued. 

But  when  the  process  is  properly  conducted  from  the  be- 
ginning up  to  this  point  the  piece  will  come  from  the  matrix 
perfect  in  all  its  parts,  and  when  the  metal  fails  to  flow  free- 
ly around  the  teeth  and  to  cover  perfectly  the  alveolar  bor- 
der and  palatine  arch,  it  is  better  to  melt  it  from  the  matrix, 
with  the  flame  of  a  spirit  lamp  projected  upon  it  with  a  blow- 
pipe, and  pouring  a  second  time — using  the  precaution  not 
to  concentrate  it  too  long  on  the  teeth,  as  in  this  case  there 
would  be  danger  of  cracking  them.  When  this  is  done,  the 
matrix  is  secured  as  in  the  first  instance. 

Before  removing  the  piece  from  the  part  of  the  matrix 
last  made,  the  cavity  in  the  plate,  if  one  has  been  formed, 
is  made  smooth  with  scrapers  and  polished  with  prepared 
chalk  on  a  wheel  brush  revolved  in  a  lathe.  The  remain- 
ing part  of  the  matrix  is  now  removed,  and  the  edges  of  the 
plate  properly  rounded  with  a  coarse  file  ;  the  asperities  of 
the  exposed  surfaces  are  removed  with  scrapers  made  for 
the  purpose^  and  if  necessary,  the  thickness  of  the  palatine 
portion  may  be  reduced.  This  done,  these  surfaces  are  rub- 
bed first  with  coarse  and  afterwards  with  fine  emery  cloth, 
then  washed  in  soap  and  water,  with  a  hard  brush,  after- 
wards burnished  and  finished  by  polishing  with  chalk  on  a 

*  The  above  solders  are  furnished  with  the  alloy  used  for  the  base.  No.  1  is  pre- 
pared tor  use  by  melting  and  pressing  it,  while  hot,  between  two  smooth  flat  sur- 
faces.    No.  2  is  made  intj  thin  plate  before  using  by  passing  through  a  rolling  mill. 

t  This  is  made  by  dissolving  pure  zinc  in  muriatic  acid  until  the  acid  can  take 
up  no  more  of  the  metal.  This  flux  improves  by  age,  and  should  not  be  used  if 
possible  to  avoid  it  for  three  months. — Book  of  Instructions  for  Mounting  Teeth  on 
the  Cheoplaatic  Procsss. 


CHEOPLASTIC   METHOD    OF   MOUNTING   TEETH.  823 

■wheel  brush  as  described  above.  The  iijiper  surface  of  the 
plate  must  not  be  scraped  as  the  accuracy  of  its  adaptation 
to  the  gums  and  palatine  arch  would  be  injured  by  it.  It 
may  be  polished  however  with  chalk  on  a  wheel  brush,  but 
every  other  part  ought  to  be  finished  in  the  neatest  and  most 
perfect  manner.  The  polishing  up  to  this  point  being  com- 
pleted, the  piece  is  put  in  a  strong  solution  of  caustic  i3ot- 
ash,  boiled  for  two  or  three  minutes^  then  washed  in  pure 
water,  wiped  dry  and  finished  by  re2)olishing  with  chalk  and 
the  brush. 

If  the  piece  is  to  be  gilded,  it  should  be  first  put  in  the 
mouth  and  worn  a  few  days,  to  ascertain  if  the  adaptation  is 
perfect,  as  any  future  alteration  would  deface  it  and  render 
a  second  covering  of  gold  necessary.  The  adjustment  being 
correct,  the  piece  is  cleansed  from  the  secretions  of  the 
mouth  and  all  foreign  matter  by  boiling  again  in  a  solution 
of  caustic  potash  and  washed  in  pure  water  ;  it  is  then  pol- 
ished with  chalk,  washed  and  wiped  dry  ;  it  is  then  put  in 
the  ''gilding  solution,"  but  during  the  deposition  of  the 
gold,  it  should  be  removed  several  times,  burnished  and 
polished  to  give  solidity  to  the  plating,  and  remedy  any  de- 
fect that  maybe  discovered.  After  a  sufficiently  thick  coat- 
ing has  been  deposited,  say  from  three  to  five  dwts.,  it  is 
finished  as  in  the  first  instance,  by  burnishing  and  polishing. 

The  practical  value  of  a  piece  is  not  enhanced  in  the 
slightest  degree  by  gilding — the  alloy  being  tasteless  and 
not  acted  upon  by  the  secretions  of  the  mouth.  Indeed,  un- 
less the  deposit  of  gold  is  tolerably  thick  and  perfect  at 
every  point,  it  is  productive  of  injury.  As  a  general  rule, 
therefore,  a  piece  may  be  said  to  be  better  without  it  than  with 
it.  For  a  description  of  the  process  of  electro-plating,  the 
reader  is  referred  to  works  devoted  especially  to  the  subject. 

In  mounting  a  set  of  teeth  for  the  lower  jaw  by  the 
Cheoplastic  process,  the  gate  through  which  the  metal  is 
poured  into  the  matrix  should  have  two  lateral  branohes — 
one  on  each  side,  to  admit  it  more  freely  than  one  can  be 


824 


CHEOPLASTIC   METHOD   OF   MOUNTING   TEETH. 


made  to  do.  The  wax  plate  should  also  be  thicker,  to  give 
suflScient  strength  and  stability  to  the  base,  but  in  every 
other  respect  the  method  of  procedure  is  almost  precisely 
the  same  as  that  described  for  an  upper  set.  For  a  partial 
lower  set,  say  for  the  molars  and  bicuspids  on  each  side^  the 
wax  j)late  should  be  extended  behind  the  remaining  front 
teeth^  and  two  or  three  thicknesses  may  be  applied  here  to 
stiffen  it  sufficiently  to  prevent  it  from  breaking  or  bending 
when  pressure  is  made  on  the  teeth  of  the  base  on  each  side. 

^^°-  24^-  In  making  an  antago- 

nizing model  for  an  en- 
tire set  of  teeth,  the  wax 
plate  of  the  model  of  the 
lower  jaw  is  stiffened  by 
the  adjustment  of  a  piece 
of  iron  wire  about  double 
the  diameter  of  a  medi- 
um sized  knitting-needle, 
bent  to  the  curvature  of  the  arch,  and  made  fast  to  the  inner 
edge  of  the  plate,  by  being  partially  imbedded  in  it.  The 
rim  of  wax  is  now  arranged  along  the  summit  of  the  alveo- 
lar borders,  and  after  being  properly  trimmed,  the  whole  is 
taken  from  the  model  and  put  in  the  mouth.  The  upper 
plate  and  rim  of  wax  is  then  adjusted  and  the  bite  of  the 
mouth  taken  and  the  antagonizing  model  made  in  the  man- 
ner as  described  for  a  full  set  of  block  teeth  to  be  mounted 
on  gold.     See  Fig.  245. 


I 


Fia.  246. 


In  Fig.  246  is  repre- 
sented a  set  of  teeth  in  an 
antagonizing  model,  the 
upper  and  lower  ready 
to  be  placed  upon  their 
respective  models  for  the 
formation  of  matrices. 

For  partial  sets  of  teeth 


the  Cheoplastic  process  is  peculiarly  applicable,  the  perfect 


I 


CHEOPLASTIC   METHOD    OF   MOUNTING   TEETH.  825 

accuracy  of  the  adaptation  of  the  base  secures  so  firm  an 
adhesion  to  the  mouth  as  to  render  clasjiing  to  any  of  the 
remaining  natural  teeth  almost  always  unnecessary.  A 
single  tooth  or  several  teeth  situated  in  different  parts  of  the 
arch,  can  be  replaced  with  the  greatest  ease,  and  they  are 
so  securely  retained  as  to  occasion  no  inconvenience  or  an- 
noyance to  the  patient.  The  only  precaution  necessary  to 
be  observed  in  their  construction,  in  addition  to  that  of  ac- 
curacy of  adjustment  and  neatness  of  execution^  is  to  thicken 
the  projections  of  the  wax  plate  between  the  remaining 
natural  teeth  sufficiently  by  adding  melted  wax,  to  j^revent 
the  liability  of  breaking.  These  portions,  when  very  na- 
row,  should  be  made  double  the  thickness  of  the  other  parts 
of  the  plate.  After  having  adjusted  the  artificial  teeth, 
and  made  them  fast  to  the  wax  plate,  the  teeth  of  the  model 
are  cut  off  before  making  the  matrix,  as  it  would  be  im- 
possible to  separate  the  two  parts  of  it  without  breaking 
them. 

A  piece  from  which  one  or  more  teeth  have  been  broken 
can  be  easily  repaired.  If  any  portion  of  the  tooth  re- 
mains it  is  removed,  and  the  metal  that  united  it  to  the  base 
filed  away.  A  new  tooth  is  selected  and  ground  until  it 
fits  the  teeth  accurately  on  each  side  of  the  aperture.  The 
floor  of  the  groove  filed  in  the  base  is  covered  with  a  piece 
of  wax  of  the  thickness  of  that  used  for  the  plate  ;  the  tooth 
is  then  put  in  place,  wax  applied  on  the  outside  of  the  up- 
per edge,  filling  the  groove  in  the  plate  ;  it  is  next  placed 
on  the  inside  side,  filling  the  hole  or  groove  in  the  back  of 
the  tooth,  designed  for  its  attachment  to  the  base.  This  is 
chiefly  done  with  the  wax  knife.  Fig.  238,  made  hot  in 
the  flame  of  a  spirit  lamp.  The  apex  of  a  roll  of  wax 
about  an  inch  and  a  half  in  length,  of  a  conical  shape,  is 
united  to  the  wax  on  the  back  part  of  the  tooth.  The  apex 
should  be  a  little  more  than  an  eighth,  and  the  base  half  an 
inch  in  diameter.  The  latter  should  be  half  an  incli  above 
the  summits  of  the  teeth.  A  small  stem  of  wax  is  united 
53 


826  CHBOPLASTIC   METHOD    OF   MOUNTING   TEETH. 

to  the  wax  on  the  outside  of  the  tooth,  with  the  free  ex- 
tremity half  au  inch  above  the  tooth. 

The  sheet  iron  or  tin  ring  employed  in  making  the  model 
is  now  filled  about  one-third  full  of  plaster  and  spar,  mixed 
with  water,  until  about  the  consistence  of  batter,  and  the 
piece  put  immediately  in  it  with  the  base  downwards,  press- 
ing upon  it  sufficiently  to  imbed  the  concave  surface.  A  thin 
mixture  of  the  same  composition  is  then  poured  on  top, 
filling  the  ring  and  covering  the  summits  of  the  teeth  about 
a  quarter  of  an  inch.  When  hard,  the  ring  is  removed^  and 
the  projecting  stems  of  wax  withdrawn.  The  wax  on  each 
side  of  the  tooth  and  between  it  and  the  base  is  melted  out 
by  throwing  the  flame  of  a  spirit  lamp  with  a  blow-pipe 
into  the  gate  behind  the  tooth  and  the  vent  in  front. 

The  matrix  thus  formed  is  dried  and  made  hot  in  a  stove 
or  furnace,  as  in  the  first  instance.  The  alloy  is  then  melted 
and  poured  into  it  through  the  gate  behind  the  tooth,  and 
if  it  comes  up,  filling  the  vent  in  front  without  bubbling, 
the  piece  wnll  come  from  the  matrix  perfectly  restored. 
When  cold,  the  plaster  and  spar  are  broken  from  the  teeth 
and  the  metal  around  the  new  tooth  finished  in  the  manner 
as  previously  described. 


4 


P^RT    SEVENTH. 


DISEASES  AND  DEFECTS  OF  THE  PALATINE  ORGANS. 


I 


I 

I 


1^-A.IlT     SEVENTH. 


DISEASES  AND   DEFECTS  OF  THE  PALATINE   ORGANS. 

Although  the  treatment  of  tlie  diseases  of  the  palatine 
organs  belong  more  properly  to  the  province  of  general 
medicine  than  to  the  specialty  to  which  the  present  treatise 
is  chiefly  devoted,  yet,  inasmuch  as  the  surgeon  dentist  is 
often  called  upon  to  remedy  the  defects  that  sometimes  re- 
sult from  them,  it  is  important  that  he  should  have,  at 
least,  some  general  knowledge  of  the  morbid  phenomena 
liable  to  be  developed  in  these  parts.  But  in  treating  of 
these  diseases,  it  is  not  the  intention  of  the  author  to  enter 
into  a  minute  description  of  their  pathology  or  therapeutical 
indications.  His  principal  object  is  to  notice  the  defects 
resulting  either  from  the  changes  of  structure  to  which  they 
are  liable  to  give  rise,  or  from  malformation,  and  to  point 
out  the  means  by  which  they  are  remedied. 

The  defects  of  the  palatine  organs  may  be  divided  into 
accidental  and  congenital.  The  first,  as  has  been  just  inti- 
mated, are  caused  by  a  pathological  change  of  structure. 
The  second  are  the  result  of  malformation  or  imperfect  de- 
velopment of  the  parts.  But  from  whatever  cause  they  may 
be  produced,  their  effects  upon  the  voice,  speech,  mastica- 
tion and  deglutition  are  the  same.  These  functions  are  all 
impaired  by  them,  in  proportion  to  their  nature  and  extent. 
When  they  extend  so  far  as  to  cause  a  complete  division  of 
the  hard  and  soft  structures,  distinct  utterance  is  wliolly 
destroyed,  and  the  acts  of  mastication  and  deglutition  are 
greatly  impaired  and  always  performed  with  difiiculty. 


830       DISEASES  AND   DEFECTS   OF   THE   PALATINE   ORGANS. 

When  the  loss  of  substance  is  the  result  of  disease,  and 
extends  so  far  as  to  establish  a  communication  between  the 
mouth  and  nasal  fossae,  the  defect  can  seldom  be  remedied 
in  any  other  way  than  by  means  of  an  artificial  obturator ; 
and  even  when  it  is  congenital,  though  the  aid  of  surgery 
may  very  often  be  successfully  invoked,  the  resources  of  art, 
in  the  majority  of  cases^  will  be  required.  'When  the  defect 
is  confined  to  the  vault  of  the  palate,  and  consists  of  a  sim- 
ple opening  between  the  mouth  and  nasal  cavities,  these 
resources  may  always  be  successfully  applied,  and  even 
when  the  loss  of  substance  extends  to  the  soft  palate,  and 
anterior  part  of  the  alveolar  ridge,  a  mechanical  appliance 
may  be  so  constructed,  as  to  restore,  in  a  great  degree,  the 
functions  dependent  upon  the  presence  and  integrity  of  the 
natural  parts. 


CHAPTER    FIRST. 

DISEASES    OF    THE    PALATE. 

In  common  with  other  parts  of  the  body,  the  palate  some- 
times becomes  the  seat  of  various  morbid  phenomena,  but 
the  occurrence  of  disease  here  is  generally  the  result  of  con- 
stitutional causes^  such  as  certain  depraved  habits  of  body. 
It  is  perhaps,  more  frequently  induced  by  secondary  syph- 
ilis than  any  other  cause,  and  when  it  is,  its  ravages  are  of- 
ten truly  deplorable.  It  may,  however,  result  from  the  im- 
moderate and  protracted  use  of  mercurial  medicine,  or  from 
a  scorbutic,  cancerous,  scrofulous  or  rickety  diathesis  of  the 
general  system.  Among  tlie  diseases  liable  to  attack  the 
palate,  are  tumors,  caries  and  necrosis  of  the  bones,  ulcera- 
tion of  the  mucous  membrane,  and  inflammation_,  elongation 
and  ulceratien  of  the  uvula.  In  consulting  writers  on  the 
diseases  of  the  palate,  the  author  has  been  able  to  find  but 
few  who  have  treated  on  them  at  much  length,  and  for  the 
information  which  he  has  been  able  to  obtain  upon  the  sub- 
ject, except  that  which  lie  has  derived  from  his  own  limited 
observations,  he  is  principally  indebted  to  Jourdain  and  Boy- 
er.  The  first  of  these  autliors  has  devoted,  in  the  first  vol- 
ume of  his  Treatise  on  the  Surgical  Diseases  of  the  Mouth, 
about  one  hundred  and  forty  pages  to  the  afi'ections  under 
consideration. 

T  U  M  0  II  S    OF    T  [1  K    PALATE. 

Tumors  of  the  palate  are  less  frequent  in  their  occurrence 
than  morbid  growths  from  the  gums  and  alveolar  processes, 
and  they  are  as  variable  in   their  appearance  and  character 


832  TUMORS   OF   THE   PALATE. 

as  are  those  which  are  developed  from  other  parts  of  the 
mouth.  tSoraetiraes  they  originate  from  the  mucous  mem- 
brane, at  other  times  from  the  periosteal  tissue.  Sometimes 
they  are  attached  by  a  broad  base  ;  at  other  times  by  a  very 
narrow  one.  Some  have  a  smooth  surface,  a  whitish  and 
pale  red  color,  and  a  firm  fleshy  texture.  These  generally 
grow  very  slowly,  and  are  seldom  of  a  malignant  character. 
Others  have  an  uneven  surface,  are  soft  and  vascular,  of  a 
purple  color^  and  bleed  from  the  slightest  injury. 

The  last  are  of  a  more  malignant  nature,  and  frequently 
have  a  cancerous  tendency.  They  are  also  more  sensitive 
to  the  touch  and  more  painful.  The  first  are  seldom  attend- 
with  much  pain,  and  are  less  dangerous.  In  forming  a 
prognosis,  therefore,  it  is  necessary  to  distinguish  between 
those  which  are  simple,  and  those  which  are  of  a  malignant 
or  cancerous  nature. 

Tumors  of  the  palate,  as  well  as  those  of  other  parts  of 
the  mouth,,  are  always  productive  of  annoyance  and  incon- 
venience to  the  patient  in  proportion  to  their  size  and  the 
malignancy  of  their  character.  They  impede,  and,  some- 
times, destroy  the  functions  of  mastication,  and  render  those 
of  speech  and  deglutition  exceedingly  diflicult  and  imper- 
fect. 

A  more  minute  description  of  tumors  of  the  palate  is 
deemed  unnecessary,  since  that  which  has  been  given,  in  a 
preceding  part  of  the  work,  of  the  morbid  productions  of 
the  gums  and  alveolar  processes,  will,  for  the  most  part,  be 
found  as  applicable  to  the  one  as  to  the  other.  But  with  re- 
gard to  the  peculiar  pathological  characteristics  and  noso- 
logical classification  of  the  various  kinds  of  tumors,  it  has 
constituted  no  part  of  the  design  of  the  author  to  attempt  a 
description.  He  could  not  do  this  without  extending  the 
limits  of  this  part  of  his  work  to  too  great  a  length  :  there- 
fore, for  information  upon  these  subjects,  the  reader  is  refer- 
red to  works  on  general  medicine  and  surgery. 


I 


CAUSES  OP  TUMORS   OF   THE  PALATE.  833 


CAUSES. 

Concerning  the  causes  of  tumors  of  the  palate,  as  well  as 
those  of  other  parts  of  the  hody,  there  exists  some  diversity 
of  opinion.  Some  authors  helieve  that  they  are  attributable 
in  all  cases  to  a  peculiar  or  specific  constitutional  vice,  as 
venereal,  scorbutic,  cancerous_,  scrofulous,  etc.,  while  others 
think  they  may  occur  in  individuals  in  whom  no  such  habit 
or  vice  exists.  That  the  character  of  the  tumor  is  determin- 
ed by  the  habit  of  body  or  constitutional  tendency  of  the 
individual  is  a  question,  we  believe,  wdiich,  at  present,  ad- 
mits of  little  doubt,  though  some  exciting  cause  may  be  ne- 
cessary to  the  commencement  of  the  disease.  Local  irritation, 
no  doubt,  is  the  immediate  or  exciting  cause  of  the  various 
morbid  productions  of  the  palate,  but  this,  unless  favored  by 
some  specific  or  peculiar  constitutional  tendency  or  cachec- 
tic habit  of  body,  would  not  be  likely  to  give  rise  to  their 
growth.  Thus,  while  the  former  would  seem  to  be  the  excit- 
ing cause,  the  character  assumed  by  the  disease,  as  has  been 
just  stated,  is  evidently  determined  by  the  latter. 

Every  habit  of  body,  or  tendency  to  any  particular  form 
of  diseased  action  may  be  regarded,  too,  as  having  a  sus- 
ceptibility to  morbid  impressions  peculiar  to  itself.  Hence, 
an  irritant  which,  in  one  case,  might  not  be  productive  of 
any  appreciable  disturbance,  might,  in  another,  give  rise  to 
a  morbid  growth  of  a  more  or  less  malignant  character — 
according  to  the  habit  of  body,  or  constitutional  tendency 
of  the  individual. 

The  irritation  produced  by  dead,  loose  and  diseased  teeth, 
ulcers  of  the  mucous  membrane  and  necrosed  bone,  are, 
perhaps,  among  the  most  common  of  the  exciting  causes. 
Some  may,  perhaps,  be  disposed  to  question  the  agency  of 
dental  irritation  in  the  production  of  a  morbid  growth  from 
the  palate,  but  the  fact  is  too  well  established  to  admit  of 
doubt.  Many  well  autlienticated  cases  are  on  record,  which 
conclusively  prove  that  diseased  teeth  are  capable  of  exert- 


834       TREATMENT  OP  TUMORS  OF  THE  PALATE. 

ing  a  morbid  influence  upon  these  parts.  M.  GtUYARD*  re- 
ports the  case  of  a  woman,  forty  years  of  age,  who  had  a 
cancerous  excrescence  of  the  palate,  caused  by  the  irritation 
produced  by  the  superior  incisors,  and  numerous  examples 
of  tumor  and  other  diseases  of  the  palate,  resulting  from 
the  presence  of  diseased  teeth,  are  given  by  Jourdain  and 
other  authors. t 

But  there  are  other  causes,  such,  for  example,  as  salivary 
calculus,  mucous  engorgement  of  the  maxillary  sinus,  acrid 
saliva,  and  mechanical  injuries  from  blows,  and  hard  sub- 
stances taken  into  the  mouth.  Roche  and  Sanson,  in  their 
Theory  and  Practice  of  Medicine  and  Surgery,  say,  that 
''from  the  irritation  produced  by  syphilitic  ulcers^  carcino- 
matous tumors  nearly  always  follow. "| 

T  R  K  A  T  M  K  N  T  . 

Although  tumors  of  the  palate  may  sometimes  disappear 
spontaneously  on  the  removal  of  the  exciting  cause,  the 
proper  curative  indication  consists  in  tlieir  entire  extirpation. 
When  they  are  attached  by  a  small  base,  this  may  be  easily 
effected  with  a  pair  of  scissors  with  properly  curved  blades, 
or  by  means  of  a  ligature  in  the  manner  as  directed  for  the 
removal  of  similar  tumors  of  the  gums.  But  when  they 
are  attached  by  a  broad  base,  a  curved  bistoury  is  the  most 
convenient  instrument  that  can  be  employed,  and  sometimes 
it  may  be  necessary  to  have  two,  a  right  and  a  left,  or  one 
for  each  side. 

Boyer  describes  an  operation  which  he  performed  for  the 
removal  of  a  hard,  white,  indolent  tumor,  of  the  size  of  a 
large  nut,  situated  a  little  behind  the  middle  of  the  palate, 
and  which  had  occasioned  the  patient,  who  was  a  lady,  no 
other  inconvenience  than  an  unpleasant  sensation  during 

*  Vide  Journal  de  Med.  tome,  xix,  p.  361. 
t  Vide  Traitg  des  Maladies  Chirurgicale  de  la  Bouche. 

t  Vide  Nouveaux  Elements  de  Fathologie  Medico-Chirurgicale,  ou  precis  Thco- 
rique  ct  Pratique  de  Medicine  et  Chirurgie,  tome  4,  p.  1011. 


TREATMENT  OF  TUMORS  OF  THE  PALATE.        835 

mastication  and  deglutition.  He  excised  the  tumor  witii  a 
bistoury,  curved  so  as  to  fit  exactly  the  vault  of  tlie  palate, 
■which  he  had  made  for  the  jDurpose.  After  having  removed 
the  tumor  he  destroyed  the  membrane  from  which  it  had 
originated,  with  a  rasp.  The  hemorrhage  was  suppressed 
with  vinegar  and  water  and  pledgets  of  lint.  The  wound 
soon  healed,  and  at  the  expiration  of  eight  years,  there  were 
no  signs  of  a  reproduction  of  the  disease.* 

In  the  removal  of  tumors  from  the  palate,  as  well  as  from 
other  parts  of  the  body,  no  portion  should  be  left  ;  as,  in 
this  event,  a  reproduction  of  the  disease  would  be  likely  to 
occur,  and  more  especially  if  it  be  of  a  malignant  character. 
The  operation  should  be  performed,  too,  before  the  tumor 
has  acquired  great  size,  or  implicated  in  the  diseased  action, 
to  a  considerable  extent,  the  neighboring  structures. 

There  is  always  great  danger  when  the  morbid  production 
is  of  a  cancerous  nature,  however  perfectly  it  may  be  removed, 
of  its  reproduction  ;  to  guard  against  this,  as  far  as  possible_, 
the  application  of  the  actual  cautery  is  recommended  by 
many  surgeons,  not  only  for  the  purpose  of  causing  exfolia- 
tion of  a  portion  of  the  superjacent  bone,  but  also  to  arrest 
the  hemorrhage  which  generally  attends  operations  of  this 
sort.  Boyer,  who  says  he  has  performed  the  operation  for 
the  removal  of  tumors  from  the  palate  several  times^  frankly 
admits  that  he  has  never  been  successful  where  they  were  of 
a  malignant  character.  But,  notwithstanding  the  great 
liability  there  is  of  a  reproduction  of  most  morbid  growths, 
this  does  not  always  happen,  as  is  well  attested  by  many 
cases  on  record,  and  from  which  it  may  be  well  to  cite  three 
or  four. 

Pierre  Guyard  reports  in  the  Journal  do  Medicine,  vol. 
xix,  p.  361,  and  to  which  reference  has  before  been  made, 
the  case  of  a  woman,  forty  years  of  age,  who  had  a  cancer- 
ous  excrescence   of  the  palate,    of  many   years   standing, 

*  Traitfi  des  Maladies  Chirurgicale  et  des  Operations,  qui  leur  Conviennent :  tome 
6,  p.  449. 


836        TREATMENT  OF  TUMORS  OF  THE  PALATE. 

wliicli  weighed  nine  ounces.  This  excrescence  was  extir- 
pated, and  the  patient  restored  to  health. 

The  case  of  a  man,  forty  years  of  age,  affected  with  so 
large  a  tumor  of  the  palate  that  he  could  take  no  nourish- 
ment, except  in  a  fluid  state,  is  reported  hy  Varner.  In 
this  case,  it  was  of  a  cartilaginous  character,  interspersed 
with  osseous  j)oints,  and  the  operation  for  its  removal  was 
also  successful.* 

Jourdain  describes  the  case  of  a  man,  who,  from  the  irri- 
tation produced  by  the  roots  of  several  decayed  teeth,  had  a 
swelling  of  the  upper  lip  and  nose,  and  a  tumor  of  the 
palate  of  the  size  of  a  pigeon's  egg.  A  fistula,  traversing 
the  alveolar  and  maxillarj'  border,  extended  from  the  supe- 
rior lateral  incisor  to  the  first  molar  of  the  same  side,  from 
which  a  large  quantity  of  matter  was  discharged.  The  teeth 
being  troublesome,  were  removed.  The  discharge  of  matter 
soon  ceased.  He  next  removed  the  tumor  from  the  palate, 
which  exposed  a  portion  of  necrosed  bone  ;  this  exfoliated 
in  a  few  days,  leaving  an  opening  into  the  nose  of  the  size 
of  a  large  quill,  through  which  fluids,  taken  into  the  mouth, 
readily  jiassed.  By  the  application  of  caustics,  the  sides  of 
the  opening  were  caused  to  granulate,  and  in  six  weeks  it 
had  entirely  healed. 

The  same  author  mentions  the  case  of  a  lady,  who  had  a 
tumor  of  the  palate,  caused  by  erysipelas.  The  last  named 
disease  having  extended  to  the  lips^  nose  and  vault  of  the 
j^alate,  caused  in  the  last  mentioned  place  ulceration,  from 
the  centre  of  which  grew  a  small  fungous  tumor.  This  was 
removed,  and  a  portion  of  the  bone,  which  was  exposed,  was 
found  to  be  in  a  necrosed  and  partially  exfoliated  condition. 
This  was  extracted  with  an  excavator,  and,  under  proper 
treatment,  the  patient  soon  recovered. 

In  presenting  the  foregoing  cases,  the  author  has  not 
thought  it  necessary  to  give  anything  more  than  the  import- 
ant facts  connected  with  each.     A  full  translation   of  the 

*  Vide  Traite  des  Maladies  Chirurgicale  de  la  Bouche,  t.  1,  p.  427. 


CARIES   AND   NECROSIS   OF   THE   BONES   OF   THE   PALATE.     83 1 

reports  would  occupy  more  space  than  he  wishes  to  devote 
to  this  particular  subject. 

It  is  seldom  that  the  operation  for  the  removal  of  tumors 
of  the  palate  are  followed  by  as  favorable  results  as  furnished 
by  the  foregoing  cases.  If  it  were  necessary,  many  examples 
of  tumors  of  the  palate,  attended  with  fatal  effects,  might 
be  cited.  Jourdain  mentions  one  given  by  M.  Plater,  of  a 
cancerous  tumor  of  the  palate,  caused  by  ulceration  of  the 
throat  and  uvula. 

Both  before  and  after  the  operation,  such  general  or  con- 
stitutional treatment  as  may  be  indicated  by  the  habit  of 
body  or  vice  under  which  the  patient  may  be  laboring, 
should  be  adopted.  If  of  a  scorbutic  or  scrofulous  habit,  or 
aft'ected  with  a  syphilitic  disease,  suitable  remedies  should 
be  prescribed,  and  when  practicable,  such  local  irritants  as 
may  have  acted  as  exciting  causes  should  be  removed. 

CARIES   AND   NECROSIS  OP    THE   BONES  OF    THE   PALATE,  AND 
ULCERATION  OF  THE   MUCOUS  MEMBRANE. 

The  bones  of  the  palate  sometimes  becomes  the  seat  of 
caries  and  necrosis,  causing  ulceration  of  the  subjacent  soft 
parts,  and  the  destruction  of  a  greater  or  less  portion  of  the 
structures  which  separate  the  cavities  of  the  mouth  and 
nose.  Although  these  effects  are  of  more  frequent  occur- 
rence than  tumors,  they  are  less  dangerous  in  their  conse- 
quences. Commencing  with  inflammation  and  suppuration 
of  the  periosteal  tissue,  caries,  and  necrosis  of  the  bones, 
accompanied  by  ulceration  of  the  subjacent  mucous  mem- 
brane^ soon  supervene,  and  ultimately  exfoliation  takes 
place,  when  an  opening  of  greater  or  less  size,  between  the 
buccal  and  nasal  cavities,  is  established. 

During  the  progress  of  the  disease,  fetid  sanies  is  con- 
tinually discharged  from  one  or  more  fistulous  openings, 
into  the  mouth,  and  sometimes  into  the  cavities  of  the  nose, 
rendering  the  condition  of  the  unhappy  sufferer  exceedingly 


838     CARIES   AND   NECROSIS   OF   THE   BONES   OF   THE   PALATE. 

loathsome  and  distressing.  The  progress  of  the  disease  is 
often  slow,  continuing,  not  unfrequently,  for  weeks,  months, 
and  in  some  cases,  even  years,  destroying  all  the  pleasures 
of  life,  and  rendering  existence  itself  a  burden.  A  case  of 
this  kind  was  recently  introduced  into  the  infirmary  of  the 
Baltimore  College  of  Dental  Surgery,  which  will  be  noticed 
at  some  length,  when  the  author  comes  to  treat  of  the 
means  employed  for  remedying  defects  of  the  palatine 
organs. 

Dr.  B.  B.  Brown,  surgeon  dentist,  formerly  of  St.  Louis, 
Missouri,  describes  a  very  interesting  case  of  the  destruction 
of  a  large  portion  of  the  palate  plates  of  the  superior  max- 
illary and  palate  bones,  accompanied  by  the  loss  of  the  left 
lateral  and  central  incisors.* 

The  ravages  of  caries  and  ulceration  of  the  palate  are 
sometimes  so  great  that  the  palatine  bones,  the  palate  plates 
of  the  superior  maxillary,  the  vomer,  turbinated  and  nasal 
bones,  together  with  the  velum  and  uvula,  are  entirely  de- 
stroyed, but  when  they  are  thus  extensive,  they  are  seldom 
arrested,  except  with  the  life  of  the  patient. 

The  ulcerative  process  of  the  soft  parts,  when  resulting 
from  caries  of  the  bones,  frequently  extends  to  the  pituitary 
membrane,  lining  the  floor  of  the  nasal  fossae.  A  case  of 
tliis  kind,  and  to  which  the  author  will  hereafter  have  occa- 
sion to  refer,  is  related  by  Jourdain. 

But  ulceration  of  the  mucous  membrane,  lining  the  vault 
of  the  palate,  often  occurs  while  the  superjacent  bones  are  in 
a  healthy  condition.  It  is  frequently  caused  by  inflamma- 
tion and  ulceration  of  the  velum  and  uvula^  whether  result- 
ing as  an  eficct  of  secondary  syphilis  or  from  malignant 
ozena  produced  by  other  causes.  But,  from  whatever  cause 
the  ulceration  is  produced,  it  may  ultimately  give  rise  to 
caries  and  necrosis  of  the  bones. 

*  Vide  Am.  Jour.  Dent.  Sci.  vol.  6,  p.  236. 


i 


TREATMENT   OF  CARIES,    &C.,    OF   PALATE  BONES.  839 


CAUSES. 

As  in  tlie  case  of  tumors  of  the  palate,  caries,  necrosis, 
and  ulceration  of  these  parts  are  the  result  of  local  irrita- 
tion and  certain  habits  of  body,  or  constitutional  vices.  The 
iramediate  or  exciting  cause  is  local  irritation,  but  the  ex- 
tent of  the  effects  resulting  from  such  irritation  is,  as  we 
have  frequently  stated  before,  in  proportion  to  the  suscepti- 
bility of  the  body  to  morbid  impressions.  The  local  irri- 
tants are  the  same  as  those  which  have  been  already  men- 
tioned, namely,  dead  and  loose  teeth,  roots  of  teeth,  sali- 
vary calculus,  mechanical  injuries,  acrid  humors,  etc.  The 
case  of  a  lady  of  irreproachable  character,  is  related  by 
Jourdain,  in  whom  a  scratch  on  the  palate  with  a  fish-bone, 
caused  a  tumor,  which  suppurated  and  degenerated  into  an 
an  ulcer,  with  hard  elevated  edges  and  a  fungus  in  the 
middle.*  A  case,  in  which  effects  similar  to  these,  and  pro- 
duced by  the  same  cause,  was  mentioned  to  the  author  in 
1849,  by  a  dentist  of  Baltimore.  Local  irritation,  unques- 
tionably, has  much  to  do  in  the  production  of  the  diseases 
under  consideration — more  than  many  seem  to  imagine  or 
are  willing  to  admit.  Most  writers  are  of  the  opinion  that 
they  are  wholly  caused  by  some  constitutional  vice,  and 
nearly  always  by  the  venereal,  but  that  this  opinion,  to 
some  extent  at  least,  is  erroneous,  will  be  fully  proven  by 
some  facts  which  will  be  presented  when  we  come  to  speak 
of  the  treatment  of  these  affections. 

TREATMENT. 

In  the  treatment  of  caries  of  the  bones  of  the  palate,  it  is 
important  to  ascertain  if  the  patient  be  laboring  under  any 
constitutional  vice  which  may  have  contributed  to  the  dis- 
ease, and  the  local  irritants  concerned  in   giving  rise  to  it. 

*  Vide  Traite  des  Maladies  Chirurgicale  de  la  Bouche,  torn.  1,  p.  407. 


840  TREATMENT   OP   CARIES,    &C.,    OF    PALATE   BONES. 

If  the  inflammation  from  wliich  it  results^  is  caused  by  me- 
chanical irritation,  the  irritants  should,  at  once^  be  re- 
moved. If  decayed,  dead,  or  loose  teeth  be  suspected  as 
having  had  any  agency  in  its  production,  they  should  be  im- 
mediately extracted,  but  so  long  as  any  portions  of  decayed 
or  necrosed  bone  remains,  it  is  needless  to  say,  tlie  ulcera- 
tions or  fistulous  openings  in  the  soft  parts  cannot  be  healed. 
These,  as  soon  as  they  have  become  sufficiently  exfoliated, 
should  be  detached  and  removed,  but  in  doing  this  it  may 
be  necessary  to  increase  the  size  of  the  external  opening. 
During  the  process  of  exfoliation,  the  mouth  should  be  fre- 
quently gargled  with  astringent  and  detergent  lotions,  for 
the  purpose  of  neutralizing  the  odor  of  tlie  offensive  matter 
which  is  continually  discharging. 

Suitable  constitutional  remedies  should,  at  the  same  time, 
be  prescribed.  As  in  the  case  of  tumors,  if  the  patient  be 
laboring  under  a  scorbutic,  scrofulous  or  venereal  diathesis 
of  the  general  system,  the  indications  should  be  properly 
fulfilled.  But  before  instituting  any  general  treatment,  we 
should  be  well  assured  that  our  diagnosis  is  correct.  A 
venereal  vice  is  sometimes  suspected  when  none  exists,  as  is 
shown  by  the  following  brief  summary  of  the  history  of  a 
case  related  by  Jourdain. 

The  subject  of  this  case,  was  a  man  who  liad  a  swelling 
which  occupied  the  whole  of  the  left  side  of  the  vault  of  the. 
palate,  from  which  there  had  been  a  fistulous  opening  for  a 
long  time.  The  edges  were  hard  and  indurated.  Venereal 
vice  was  suspected  as  the  cause,  and  for  which  disease, 
treatment  was  proposed,  but  the  patient  not  being  willing 
to  submit,  Jourdain  was  consulted,  who  advised  the  removal 
of  the  roots  of  three  or  four  teeth  in  the  vicinity  of  the  dis- 
ease. This  operation  was  performed  and  the  fistulous  open- 
ing at  the  same  time  enlarged,  when  the  bone  was  found  to 
be  in  a  carious  condition,  but  with  little  other  treatment  a 
complete  cure  was  soon  effected.* 

•  Vide  Traitedea  Maladies  Chirurgicale  dela  Bouche,  torn.  1,  p.  406. 


TREATMENT  OF  CARIES,  &C.,  OF  PALATE  BONES.     841 

That  the  effects  resulting  from  dental  irritation  may  ex- 
tend to  the  palate,  is  shown  by  the  following  particulars  of 
a  case  taken  from  the  history  of  one  given  by  the  same 
author. 

A  man  called  upon  Joiirdain  for  advice,  in  relation  to  a 
tumor  of  the  vault  of  his  palate.  Upon  examination,  a 
sensible  fluctuation  was  perceived ;  on  being  pressed,  fetid 
pus  escaped  from  a  small  fistulous  opening  between  the  right 
lateral  incisor  and  canine  tooth,  and  also  from  the  socket  of 
the  second  bicuspid,  which  had  been  extracted  a  short  time 
before.  The  opening  from  the  alveolus  of  this  tooth  com- 
municated with  the  first  mentioned  fistule  and  the  disease 
in  the  palate.  Notwithstanding  these  two  outlets  for  the 
escape  of  the  matter,  it  increased  in  the  palate.  Various 
means  were  resorted  to  for  the  cure  of  the  disease,  but  with- 
out success.  The  nasal  fossge,  by  the  accumulation  of  mat- 
ter, were  partially  closed,  the  alveoli  of  the  lateral  incisor, 
cuspidatus  and  first  bicuspid  became  necrosed_,  the  teeth 
loosened,  and  were  extracted.  The  alveoli  exfoliated,  the 
tumor  of  the  palate  was  opened,  when  the  bones  of  the 
palate  and  maxillary  alveolar  borders  were  found  in  a  ne- 
crosed and  partially  exfoliated  state.  These  were  removed 
without  much  diflSculty,  and  left  an  opening  through  to  the 
pituitary  membrane  which  lined  the  floor  of  the  nasal  fossee. 
These  portions  of  bone  having  been  removed,  the  parts  soon 
healed.* 

That  the  caries  in  the  two  last  cases  was  caused  by  den- 
tal irritation,  there  can  be  no  question,  and  that  it  often 
results  from  this  cause,  we  have  not  the  least  doubt.  In  the 
last  case,  it  is  probable  that  the  second  bicuspid  of  the 
affected  side,  was  not  extracted  until  an  abscess  had  formed 
at  the  extremity  of  its  root,  and  that  the  matter,  instead  of 
escaping  externally,  had  effected  a  passage  through  the  in- 
ner wall  of  the  alveolus  and  thence  between  the  palate  plate 
of  the  superior  maxillary  and  mucous  membrane  to  near 

*  Vide  Traite  dee  Maladies  Chirurgicale  de  la  Bouche.  t^aie.  1,  p.  397. 

54 


842  INFLAMJL\TION   OF   THE   VELUM   AND   UVULA. 

the  median  line,  where  it  had  accumulated,  produced  the 
tumor  mentioned  by  Jourdain,  and  ultimately  made  a  pas- 
sage for  its  escape  between  the  lateral  incisor  and  cuspi- 
datus.  Several  cases,  followed  by  very  similar  effects,  have 
fallen  under  the  immediate  observation  of  the  author. 

But  when  favored  by  a  cachectic  habit  of  body  or  venereal 
vice,  the  effects  are  more  destructive,  and  in  this  case,  local 
treatment  will  not  suffice. 

Ulceration  of  the  palatine  mucous  membrane  may  occur 
without  caries  of  the  subjacent  bone ;  it  may  result  as  a  con- 
sequence of  ulceration  or  other  disease  of  the  velum  or 
uvula,  or  from  some  mechanical  injury  inflicted  upon  the 
parts.  When  it  is  of  a  simple  nature,  cooling  and  astrin- 
gent gargles,  preceded  by  mild  aperients,  will  generally 
suffice  for  its  cure.  If  dependent  upon  a  specific  constitu- 
tional tendency  or  vice,  appropriate  general  remedies  should 
be  employed.  But  with  regard  to  the  treatment  of  ulcers 
of  the  palate,  we  shall  have  occasion  to  speak  when  we  come 
to  treat  of  the  diseases  of  the  velum  and  uvula. 

INFLAMMATION  AND  ULCERATION    OF   THE   VELUM  AND   UVULA. 

The  velum  palati  and  uvula  sometimes  become  the  seat  of 
inflammation,  accompanied  by  pain,  increased  redness,  diffi- 
cult deglutition  and  articulation  of  speech.  Most  frequently 
it  terminates  in  resolution,  but  sometimes  in  ulceration, 
and  at  other  times  in  gangrene.  "When  resolution  is  the 
termination^,  it  gradually  subsides,  after  having  continued 
for  a  greater  or  less  length  of  time.  When  by  ulceration, 
one  or  more  white  or  ash  colored  spots  appear  upon  the 
velum  and  uvula,  after  it  has  continued  for  a  certain  period, 
and  when,  by  gangrene,  the  part,  after  having  assumed  a 
dark  purple  or  almost  black  color,  sloughs.  This  latter 
termination,  fortunately,  rarely  happens. 

As  a  consequence  of  inflammation,  the  uvula  sometimes 
becomes  tumefied  and  elongated;  at  other  times  it  be- 
comes elongated   when  there  is  no  apparent   tumefaction. 


INFLAMMATION   OF  THE  VELUM  AND   UVULA.  843 

In  the  latter  case,  it  is  vulgarly  termed  a  ^'falling  of  the 
palate."  Most  frequently  when  it  is  elongated,  its  thick- 
ness is  at  the  same  time  increased.  In  this  case  there  is  an 
increase  of  redness,  hut  when  there  is  elongation,  without 
an  increase  of  size,  resulting  simply  from  relaxation  of  the 
part,  its  color,  instead  of  being  heightened,  is  often  dimin- 
ished, presenting  a  whitish  or  semi-transparent  appearance. 
This  description  of  elongation  is  termed  serous  tumefaction 
of  the  uvula.     It  is  seldom  accompanied  by  pain. 

When  the  uvula  becomes  so  much  elongated  as  to  rest 
upon  the  tongue,  it  causes  irritation,  difficult  deglutition, 
oftentimes  a  sense  of  suflbcation,  the  frequent  expulsion 
of  mucus  from  the  throat,  and  sometimes  a  disagreeable 
cough. 

Ulcers  of  various  kinds  sometimes  attack  these  parts, 
though  they  are  less  subject  to  them  than  are  the  other 
parts  of  the  mouth,  fauces  and  tonsils.  Sometimes  the 
ulcers  are  of  a  simple  nature,  at  other  times  they  are 
aphthous,  scrofulous,  scorbutic,  venereal  or  cancerous,  ac- 
cording to  the  specific  poison  or  diathesis  which  has  given 
rise  to  them.  When  the  ulcer  is  not  dependent  upon  con- 
stitutional causes,  it  is  termed  a  simple  ulcer,  and  is  nothing 
more  than  a  granulating  sore  which  secretes  healthy  puru- 
lent matter. 

Aphthous  ulcers  at  first  appear  in  the  form  of  whitish  or 
transparent  vesicles,  which  break,  and  are  ultimately  trans- 
formed into  ulcers,  either  surrounded  by  a  slightly  elevated 
edge  of  a  reddish  color,  or  spread  and  unite  with  each  other. 
The  former  are  termed  discrete,  and  the  latter  confluent, 
aphthae.  But  ulcers  of  this  kind  generally  appear  in  other 
parts  of  the  mouth  and  fauces  before  they  attack  the  velum 
and  uvula  of  the  palate. 

The  velum  and  uvula  are,  perhaps,  more  subject  to  vene- 
real, than  to  any  other  kind  of  ulcers.  The  characteristics 
of  these  are,  sometimes,  very  similar  to  ulcers  which  result 
from  some  other  specific  constitutional  vice,  and  their  char- 
acter can  only  be  positively  determined  by  ascertaining  all 


844      CAUSES  OF  INFLAMxMATION  OF  THE  VELUM  AND  UVULA. 

the  other  circumstances  connected  with  the  history  of  the 
case.  They  are  generally  preceded  by  ulceration  of  the 
throat,  dull  heavy  pain,  especially  at  night,  increased  red- 
ness of  the  parts,,  swelling  of  the  uvula,  and  difficult  deglu- 
tition. They  usually  have  a  whitish,  dirty  gray,  or  ash 
colored  appearance,  with  slightly  elevated  and  irregular 
margins,  and  secrete  thin  ichorous  matter  of  a  very  fetid 
odor.  The  surrounding  parts  are  preternaturally  red,  and 
sometimes  present  an  almost  purple  appearance.  At  other 
times  the  ulcers  appear  in  the  form  of  aphthous  specks,  fol- 
lowed by  sloughing  of  the  surrounding  parts.  Sometimes 
the  ulcers  attack  the  posterior  side  of  the  velum  and  uvula 
first,  where  they  commit  extensive  ravages  before  they  ap- 
pear anteriorly.  From  these  parts  they  often  extend  to  the 
vault  of  the  palate,  but  more  frequently,  when  they  appear 
here,  the  periosteal  tissue  and  bones  are  diseased  before 
ulceration  shows  itself  in  the  mucous  membrane. 

Ulcers  of  the  velum  and  uvula  sometimes  arise  as  a  con- 
sequence of  protracted  and  immoderate  use  of  mercury. 
When  they  result  from  this  cause,  they  are  preceded  by  a 
copperish  taste  in  the  mouth ;  increased  flow  and  viscidity 
of  the  saliva;  tumefaction  and  iDcreased  sensibility  of  the 
f^ums,  looseness  of  the  teeth  ;  a  peculiarly  disagreeable  odor 
of  the  breathy  general  debility  and  emaciation,  and  some- 
times diarrhea.  The  gums,  edges  of  the  tongue,  mucous 
membrane  about  the  angles  of  the  jaws,  inner  surface  of  the 
cheeks  and  throat,  ulcerate  before  tlie  velum  and  uvula  are 
attacked. 

The  velum  and  uvula  are  sometimes  the  seat  of  other  bad 
conditioned  ulcers,  such  as  the  cancerous,  scrofulous,  etc. 

CAUSES. 

Inflammation  of  the  velum  and  uvula  most  frequently  re- 
sult from  irregular  exposure  to  cold  and  moisture,  though 
it  may  sometimes  be  produced  by  local  irritation,  as  me- 
chanical injury,  acidity  of  tlie  gastric  and  buccal  fluids. 


TREATMENT  OF  INFLAMMATION  OF  VELUM  AND  UVULA.       845 

Ulceration  of  the  parts  may  result  from  the  same  causes,  but 
the  character  which  the  ulcer  assumes  is  determined  by  the 
habit  of  body,  or  peculiar  diathesis  of  the  general  system. 
Elongation  of  the  uvula  is  caused  either  by  inflammation 
and  general  enlargement,  relaxation  of  the  parts,  or  serous 
infiltration  of  its  apex. 

TREATMENT. 

For  simple  inflammation  of  the  velum  and  uvula^  unac- 
companied by  fever  or  other  general  constitutional  efiects, 
little  else  will  be  required  than  gargling  the  throat  with  an 
infusion  of  capsicum,  sweetened  with  honey.  When  the 
inflammation  is  severe^  and  the  vessels  have  the  appearance 
of  beiQg  distended,  advantage  may  be  derived  from  scarify- 
ing the  parts. 

But  when  the  uvula  is  so  much  elongated  as  to  rest  upon 
the  tongue,  and  cause  a  sensation  of  sufi'ocation  or  a  trouble- 
some cough,  if  it  does  not  yield  to  exciting  and  astringent 
gargles,  it  may  become  advisable  to  remove  a  portion  of  it. 

Fig.  247. 


For  this  operation,  though  an  exceedingly  simple  one,  a 
variety  of  instruments  have  been  invented.  The  best  how- 
ever, ^hich  the  author  has  seen,  is  the  one  invented  a  few 
years  ago  by  the  late  Dr.  S.  P.  Hullihen,  of  Wheeling,  Va. 
This  instrument;,  although  very  simple  in  its  construction^ 
is  an  exceedingly  useful  one,  for,  at  the  same  time  it  cuts 


846      TREATMEFT  OF  INFLAMMATION  OF  VELUM  AND  UVULA. 

the  uvula,  it  secures  tlie  excised  extremity,  and  prevents  it 
from  falling. 

The  construction  of  this  instrument,  and  the  manner  of 
using  it  are  so  very  simple,  that  the  accompanying  engrav- 
ing will  supersede  the  necessity  of  any  description.* 

For  a  simple  ulcer  of  the  velum  or  uvula,  no  other  treat- 
ment will  be  required  than  to  gargle  the  throat  occasionally 
with  some  gently  stimulating  and  astringent  lotion ;  the 
one  recommended  for  inflammation  of  these  parts,  may  gen- 
erally he  employed  with  advantage. 

In  the  treatment  of  venereal  or  syphilitic  ulcers  of  the 
velum  and  uvula,  little  advantage  will  he  obtained  from 
local  remedies.  They  can  only  be  cured  by  appropriate 
constitutional  treatment,  such  as  is  prescribed  in  works  on 
general  medicine  and  surgery.  To  these,  therefore,  the 
reader  is  referred  for  information  upon  this  subject. 

In  cases  of  mercurial  ulcers,  it  is  desirable  that  two  or 
three  liquid  evacuations  from  the  bowels  should  be  procured 
daily.  For  this  purpose,  sulphate  of  magnesia  or  sublimed 
sulphur  may  be  administered  night  and  morning.  The 
mouth  should,  at  the  same  time,  be  gargled  six  or  eight 
times  a  day  with  some  gently  astringent  lotion.  A  weak 
solution  of  the  sulphate  of  zinc,  or  alumina,  sweetened  with 
honey,  may  sometimes  be  advantageously  employed,  but 
more  benefit,  perhaps,  will  be  derived  from  the  use  of  a  so- 
lution of  the  chloride  of  lime.  When  the  pain  is  so  severe 
as  to  prevent  rest,  opium  should  be  prescribed.  The  diet 
of  the  patient,  for  the  most  part,  should  consist  of  farina- 
ceous substances,  and  after  tlie  ulcers  have  began  to  heal, 
milk,  light  soups,  etc.,  may  be  recommended. 

In  the  treatment  of  scirrhous  and  other  ill-conditioned 
ulcers  of  the  velum  and  uvula,  dependent  upon  a  cachec- 
tic habit  of  body,  it  is  necessary  that  the  constitutiooal  in- 
dications should  be  properly  fulfilled,  and  that  the  fitiated 
action  of  the  disease  should  be  changed  by  the  application 

•An  engraving  and  description  of  Dr.  Hullihen's  uvula  scissors  is  contained  in 
vol.  7,  No.  3,  of  Am.  Jour,  and  Lib.  of  Dental  Science, 


TREATMENT  OF  INFLAMMATION  OF  VELUM  AND  UVULA,      847 

of  local  irritants,  such  as  caustics.  The  application  of  the 
actual  cautery  has  been  found  more  eflScient  in  changing 
the  condition  of  ulcers  of  this  sort,  and  exciting  a  healthy 
action  in  them,  than  any  other  means  which  have  been  em- 
ployed. 

For  cancerous  ulcers,  it  has  been  found  necessary  to  re- 
move a  greater  or  less  portion  of  the  velum  and  uvula,  and 
even  this  operation  has  seldom  proved  successful ;  for  the 
disease,,  after  a  greater  or  less  length  of  time,  reappears 
in  some  of  the  neighboring  parts. 


CHAPTER    SECOND. 
DEFECTS    OF    THE    PALATINE    ORGANS. 

The  nature  and  extent  of  the  defects  of  the  palatine  or- 
gans are  various.  They  sometimes  consist  of  a  simple  per- 
foration of  the  vault  of  the  palate  ;  this  may  be  either  in 
the  centre,  or  on  either  side  of  the  median  line.  At  other 
times,  the  loss  of  substance  extends  to  the  entire  vault  and 
velum.  Nor  is  the  loss  always  confined  to  these  parts  ;  it 
sometimes  extends  to  the  anterior  part  of  the  alveolar  bor- 
der, and  a  portion  of  the  upper  lip,  constituting  what  is 
usually  termed  hare-lip. 

The  defects  of  the  palatine  organs,  as  we  have  before 
stated,  maybe  divided  into  accidental  and  congenital.  The 
first,  we  have  said,  results  from  accidental  causes — the  sec- 
ond from  malformation  of  the  parts. 

ACCIDENTAL    DEFECTS. 

Accidental  lesions  of  the  palatine  organs  are  divided  by 
M.  Delabarre  into  three  species.  The  first  consists  in  per- 
forations of  the  vault  of  the  palate  ;  the  second,  in  perfora- 
tions of  the  velum,  and  the  third,  in  the  destruction  of  the 
entire  vault  of  the  palate,  or  of  a  great  portion  of  it.  To 
this  last  might  also  be  added  the  destruction  of  the  whole, 
or  a  large  portion  of  the  velum,  as  well  as  of  the  vomer, 
part  of  the  alveolar  border  and  turbinated  bones.* 


*  Vide  Traitg  de  la  Partis  M6chanique  de  I'Art  du  Chirurgien  Dentiste,  t.  1,  p. 
294. 


CONGENITAL  DEFECTS   OP   THE  PALATINE   ORGANS.  849 

It  has  also  been  remarked,  that  lesions  of  the  palate  and 
velum,  resulting  from  disease,  differ  from  congenital  de- 
fects. The  first  most  frequently  perforate  the  side  of  the 
palatine  vault,  and  communicate  with  only  one  nostril, 
whereas,  the  latter,  as  will  presently  be  seen,  occupies  the 
centre  of  the  arch,  and  penetrates  both  of  the  nasal  cavities. 

The  causes  of  accidental  lesions  or  defects  of  the  palate 
and  velum,  have  already  been  treated  of,  and  the  manner  of 
rem&dying  them  will  hereafter  be  described. 

CONGENITAL    DEFECTS. 

Congenital  defects  of  the  palate  occupy  the  median  line 
or  palatine  raphae,  and  consist  in  a  division  of  the  osseous 
and  soft  textures,  of  greater  or  less  extent.  This  division 
is  sometimes  confined  to  the  vault  of  the  palate  ;  at  other 
times  the  velum,  anterior  part  of  the  alveolar  arch  and  up- 
per lip  participate.  It  forms  a  communication  with  both 
nostrils,  and  when  the  malformation  extends  to  the  alveolar 
border,  and  upper  lip,  which  is  divided  vertically  in  one, 
and  sometimes  in  two  places,  it  gives  to  the  mouth  a  most 
disagreeable  aspect.  But  hare-lip  is  sometimes  met  with 
when  there  is  no  imperfection  of  the  osseous  structures,  and 
imperfections  are  often  met  with  here  when  the  lip  is  per- 
fect. In  some  cases  the  cleft  or  fissure  is  more  than  three- 
fourths  of  an  inch  wide  throughout  the  whole  extent  of  the 
palate  and  velum,  accompanied  by  absence  of  the  whole 
of  that  portion  of  the  alveolar  border  Avhich  should  be 
occupied  by  the  four  incisors  ;  at  other  times  the  alveolar 
arch  is  divided  in  two  places,  leaving  a  portion  between  the 
lateral  and  central  incisors,  or  one  lateral  and  one  central, 
after  projecting  more  or  less,  and  thus  very  greatly  increas- 
ing the  deformity.  Although  a  double  hare-lip,  with  two 
divisions  of  the  alveolar  border,  is  seldom  met  with  without 
some  defect  of  the  palatine  organs,  cases  do  occasionally  occur. 
Dr.  Sims,  a  skillful  and  ingenious  surgeon,  formerly  of  Mont- 
gomery, Ala.,  describes  a  most  interesting  case  of  this  kind, 


850  CONGENITAL  DEFECTS   OF   THE  PALATINE   ORGANS. 

in  vol.   5tli,  page  51,  of  the  American  Journal  of  Dental 
Science. 

Congenital  defects  of  tlie  palate  are  sometimes  accom- 
panied by  more  or  less  deformity  of  the  sides  of  the  alveo- 
lar arch,  and  of  the  teeth.  Sometimes  the  sides  of  the  al- 
veolar ridge  are  forced  too  far  apart,  and  at  other  times  they 
are  too  near  each  other,  while  the  teeth  are  either  too  large 
or  too  small,  with  imperfectly  developed  roots,  and  gene- 
rally of  a  soft  texture.  * 

Want  of  coaptation,  resulting  from  defect  of  formation 
in  the  palatine  plates  of  the  maxillary  and  palatine  bones, 
are  the  cause  of  congenital  deficiencies  of  the  parts  in  ques- 
tion. But  that  such  malformation  should  occur  here  while 
all  the  other  parts  of  the  body  are  well  develoijed,  is  wholly 
inexplicable,  though  not  more  strange  than  that  other  or- 
gans, as  the  liands,  feet,  &c.,  should  be  deformed,  while 
these  parts  are  perfect.  What  it  is  that  interferes  with  the 
1  aws  that  govern  the  development  and  growth  of  the  organs 
of  the  body  during  intra-uterine  existence,  is  a  mystery 
which  physiology  has  not  yet  been  able  fully  to  unravel. 

Thus  it  is  seen,  that  the  defects  of  the  palatine  organs 
which  result  from  malformation,  present  as  much  diversity 
of  character  as  do  those  which  are  produced  by  disease,  or 
other  accidental  causes.  Mr.  Stearns,  of  London,  in  a  very 
able  and  highly  interesting  paper,  published  in  the  London 
Lancet,,  on  '^Congenital  Fissure  of  the  Palate,"  in  noticing 
their  various  anatomical  peculiarities  divides  them  into  three 
classes. 

The  first  class  embraces  all  the  cases  in  which  the  fissure 
extends  through  the  velum,  palate,  and  maxillary  bones,  t( 
the  alveolar  border,  and,  sometimes,  ''tlirough  the  whole 
extent  of  the  median  symphysis."  This  form  of  fissure  ifi 
the  most  extensive,  and  justly  regarded  as  the  worst,  and 
usually  complicated  with  hare-lip." 

In  the  second  class  the  bones  of  the  palate  are  ''appa-j 
rently  entire,  though  the  concavity  of  the  arch  may  b^ 
somewhat  greater  than  usual,  and  the  fissure"  extend  a' 


DEFECTS  OF  THE  PALATINE  ORQANS.  851 

short  distance  into  their  '  'posterior  margin. ' '    The  lesion ,  in 
this  case,  is  almost  wholly  confined  to  the  velum  palati. 

The  third  class  embraces  those  cases  in  which  the  fissure 
is  confined  to  the  soft  parts,  extending,  perhaps,  only  a 
short  distance  up  into  the  uvula.  This  form  of  fissure 
is,  probably,  less  frequently  met  with  than  either  of  the 
preceding. 

FUNCTIONAL  DISTURBANCES,  RESULTING  FROM   DEFECTS  OF  THE 
PALATINE  ORGANS. 

The  principal  effects  resulting  from  an  absence  of  a  por- 
tion of  the  palatine  organs,  are,  as  we  have  before  stated, 
an  impairment  of  the  functions  of  mastication,  deglutition 
and  speech.  Distinct  utterance  is  sometimes  wholly  de- 
stroyed, and  mastication  and  deglutition  are  often  so  much 
embarrassed  as  to  be  performed  only  with  great  difficulty. 
These  effects  are  always  in  proportion  to  the  extent  of  the 
separation  or  deficiency  of  the  parts.  But  in  noticing  the 
effects  which  result  from  absence  of  a  portion  of  the  pala- 
tine organs,  we  shall  first  speak  of  those  which  are  produced 
upon  the  functions  of  mastication  and  deglutition. 

Although  the  simple  act  of  triturating  the  food,  may  not 
be  materially  impaired  by  the  absence  of  a  portion,  however 
extensive,  of  the  palatine  organs^  unless  the  natural  rela- 
tions of  the  teeth  of  the  upper  and  lower  jaws  are  changed, 
still  tlie  process  is  more  or  less  interfered  with_,  as  substances 
taken  into  the  mouth  cannot  be  so  readily  managed,  as  when 
the  parts  are  in  their  natural  state.  They  are  constantly 
escaping  from  the  control  of  the  tongue,  and  passing  up  into 
the  cavity  of  the  nose. 

In  cases  of  congenital  defects  of  the  palate  and  velum,  it 
is  difficult  to  conceive  how,  in  infancy,  the  child  manages 
to  obtain  from  the  breast  of  its  mother  or  nurse,  the  food 
necessary  for  its  subsistence  ;  yet,  even  where  the  anterior 
part  of  the  alveolar  border,  and  a  part  of  the  upper  lip  are 


852  DEFECTS  OF  THE  PALATINE  ORGANS. 

wanting,  it  does,  in  accordance  with  the  suggestions  of  natu- 
ral instinct,  by  means  of  a  peculiar  mechanical  process, 
contrive  to  do  it.  The  expedient  to  which  it  resorts  for 
efifecting  this  process  is  curious.  The  nipple,' instead  of  be- 
ing seized  between  the  tongue,  upper  lip  and  gum  of  the  al- 
veolar border,  is  taken  between  its  lower  surface,  and  the 
under  lip  and  gum  of  the  inferior  alveolar  ridge,  and  in  this 
way  it  manages  to  extract  the  nourishment  necessary  for  its 
subsistence  and  growth.  The  tongue,  as  is  remarked  by  M. 
Delabarre,  is  thus  made  to  chise  the  opening  in  the  palate, 
and  perform  the  office  of  an  obturator.  By  contracting  the 
lip  and  depressing  the  tongue,  the  milk  is  drawn  from  the 
breast  of  the  mother  or  nurse.  At  this  young  and  tender 
age,  the  child  is  not  conscious  of  the  imperfection  of  its  palate, 
and  it  is  not,  until  the  period  arrives  wlien  it  should  begin 
to  make  its  wants  known  by  words,"'as  is  remarked  by  the 
author  just  mentioned,  that  it  feels  tlie  importance  of  the 
functions  of  sj)eech  and  begins  to  realize  the  misfortune 
with  Avhich  it  is  afflicted. 

But  as  the  child  arrives  at  this  period,  the  mechanism  of 
sucking,  as  M.  Delabarre  observes,  is  perfected,  and  ulti- 
mately applied  to  the  mastication  of  solid  aliments.  "When 
chewed,  it  is  conveyed  between  the  tongue  and  movable 
floor,  which  serves  for  a  point  d'appui  to  it,  and  thence  it  is 
brought  back  between  the  teeth.  Tluis  it  is,  that  the  com- 
plicated operation  of  mastication  and  deglutition  is  performed 
without  the  alimentary  morsel  getting  into  the  nose  ;  or,  if 
this  does  sometimes  happen,  it  is  the  result  of  accident." 
But  in  cases  of  accidental  lesion  of  the  palate,  the  individual 
has  not  the  advantage,  as  the  author  just  quoted  observes, 
"of  early  infancy."  Those  who  are  afflicted  with  acciden- 
tal lesions,  no  matter  what  may  be  their  position  and  ex- 
tent, "having,"  as  the  author  says,  "acquired  the  habit  of 
eating,  by  placing  the  aliment  on  the  tongue,  can  take  no 
nourishment,  without  a  part  of  it  getting  into  tlie  nose." 
When  to  this  inconvenience  is  added  a  change  in  the  natu- 
ral relations  of  the  teeth  of  the  two  jaws,  mastication  is 


DEFECTS  OF  THE  PALATINE  ORGANS .  853 

rendered  still  more  difficult  and  embarrassing.  When  tliis 
is  the  case,  the  tubercles  of  the  teeth  of  one  jaw,  instead  of 
being  received  into  the  depressions  of  those  of  the  other, 
strike  upon  their  protuberances,  and  cannot  be  made  to 
triturate  the  food  in  as  thorough  and  perfect  a  manner  as  is 
required  for  healthy  and  easy  digestion.  Thus,  not  only  is 
the  process  of  mastication  rendered  imj)erfect,  but  it  is  also 
more  tedious. 

Tlie  process  of  deglutition  itself,  so  long  as  the  velum 
and  uvula  are  perfect,  is  not  materially  aifected  by  a  perfo- 
ration simply  of  the  vault  of  the  palate,  although  much 
difficulty  may  be  experienced  in  conveying  alimentary  and 
fluid  substances  to  the  fauces  and  pharynx.  But  when  this 
curtain  is  cleft  or  jmrtially  or  wholly  wanting,  it  is  ren- 
dered very  difficult,  for,  by  the  contraction  of  the  muscles 
of  the  pharynx,  part  of  them  are  forced  up  into  the  nose. 
The  reason  of  this  will  appear  obvious,  when  we  take  into 
consideration  the  form  and  functions  of  this  movable  appen- 
dage, "When  its  muscles  are  relaxed,  it  forms  a  slightly 
concave  curtain  ;  but  in  the  act  of  deglutition,  the  muscles 
contract,  raise  the  velum  and  close  the  opening  from  the 
pharynx  into  tlie  posterior  nares.  Thus  alimentary  sub- 
stances and  fluids  are  prevented  from  escaping  into  the  nose. 

It  matters  not,  therefore,  whether  the  imperfection  of  the 
velum  palati  be  the  result  of  accident  or  disease^  its  effects 
upon  deglutition  arc  the  same.  In  proportion  as  the  lesion 
or  deficiency  is  great,  will  this  operation  be  rendered  diffi- 
cult and  embarrassing.  M.  Delabarre  mentions  the  case  of 
an  individual,  who^  in  'consequence  of  an  imperfection  of 
the  palate,  could  swallow  no  fluids  without  a  part  being 
returned  by  the  nose.  To  obviate  this  inconvenience,  he  had 
to  throw  his  head  sufficiently  ftir  back  to  precipitate  them 
into  the  esophagus.  This  is  an  expedient  to  which  others, 
thus  affected,  have  been  compelled  to  resort. 

Irajierfection  of  speech  always  results  from  an  opening  in 
the  palate,  for  this  gives  to  the  voice  a  nasal  twang,  and 


854  DEFECTS   OF  THE   PALATINE   ORGANS. 

renders  the  formation  of  some  sounds  impossible.  The  loss 
of  the  teeth,  though  never  to  the  same  extent,  is  productive 
of  the  same  effect.  But  to  fully  comprehend  the  manner  in 
which  a  lesion  of  the  palate  may  affect  the-  utterance  of 
speech,  it  will  be  necessary  to  understand  the  agency  which 
the  several  parts  of  the  mouth  have  in  the  formation  of 
articulate  sounds. 

Speech  consists  in  the  combination  of  sounds  produced  by 
the  organs  between  the  glottis  and  external  opening  of  the 
mouth.  The  co-operation  of  the  several  parts  of  the  mouth 
are  necessary  for  the  formation  of  most  sounds,*  and 
hence,  if  any  of  these  be  defective  or  wanting,  the  power 
of  forming  such  sounds  is  either  partially  or  wholly  de- 
stroyed. 

*  Muller's  Physiology,  vol.  2,  p.  1045. 


I 


CHAPTER     THIRD. 

MANNER  OF  REMEDYING  DEFECTS  OF  THE  PALATINE 

ORGANS. 

Defects  of  the  palatine  organs  are  sometimes  remedied 
by  means  of  a  surgical  operation,  termed  staphyloraphy ; 
but  more  frequently,  by  supplying  the  deficiency  of  the  nat- 
ural parts  with  a  mechanical  substitute.  The  operation  of 
staphyloraphy,  when  it  can  be  successfully  performed,  is 
the  best  and  most  perfect  method  that  can  be  adopted  for 
remedying  imperfections  of  the  parts  in  question.  The  ap- 
plication of  a  mechanical  substitute,  though  it  may  not 
completely  restore  the  functions  dependent  upon  the  integ- 
rity of  the  natural  parts,  will  often  so  improve  them,  as  to 
render  the  inconveniences  resulting  from  their  imperfection, 
scarcely  perceptible. 

In  treating  upon  the  above  methods,  we  shall  first  de- 
scribe the  operation  of  staphyloraphy,  and,  afterwards,  the 
various  mechanical  appliances  employed  for  the  purpose, 
which  are  designated  by  the  names  of  obturators  and  arti- 
Jicial  palates. 

STAPHYLORAPHY. 

It  rarely  happens,  except  in  cases  of  congenital  fissure, 
that  the  operation  of  staphyloraphy  can  be  successfully  per- 
formed, and  only  then,  when  the  edges  of  the  cleft  velum 
are  firm  and  can  be  easily  brought  together.  There  are 
many  ways  by  which  the  success  of  the  operation,  even  in 
apparently  the  most  favorable  cases  may  be  defeated.     For 


856  STAPH  YLORAPHY. 

example,  the  ligatures  may  be  detached  by  attempting  to 
swallow,  or  clear  the  throat,  or  by  coiighing_,  sneezing,  or 
by  inflammation  and  sloughing  of  the  parts.  Unless  these 
are  carefully  guarded  against,  the  best  eiforts  of  the  surgeon 
may  be  frustrated. 

The  idea  of  this  operation  was  first  conceived  by  an  in- 
genious French  dentist,  by  the  name  of  Le  Monnier,  who 
attempted,  and  with  success,  to  perform  it  as  early  as  the 
year  1764.  But  for  more  than  half  a  century  afterwards, 
it  does  not  seem  to  have  attracted  any  attention,  or  to  have 
been  generally  known  to  the  medical  profession.  In  1819, 
however,  M.  Roux,  a  celebrated  French  surgeon,  and  au- 
thor of  an  able  memoir  upon  the  subject,  published  in  1825, 
performed  the  operation  upon  Dr.  Stephens,  a  young  Amer- 
can  physician.*  In  1820,  it  was  performed  for  the  first 
time  in  the  United  States,  by  Dr.  J.  C.  Warren,  of  Boston, 
and  in  1822  in  England,  by  Mr.  ALCocK.f  Now,  it  is  class- 
ed among  the  regular  operations  of  surgery. 

As  the  success  of  the  operation  depends  in  a  great  degree 
upon  the  consent  of  the  patient,  he  should,  as  a  general 
rule,  have  attained  a  sufficient  age  to  enable  him  to  appre- 
ciate its  importance,  before  it  is  performed.  Dr.  HuUihen, 
however,  a  scientific  dentist  of  Wheeling,  Va.,  says,  he  has 
performed  the  operation  with  success  on  a  child  of  nine  years 
of  age,  but  the  author  is  of  the  opinion,  that  it  is  generally 
better  to  defer  it  until  after  the  fifteenth  or  sixteenth  year  ; 
and  the  natural  excitability  of  the  parts  should  be,  previous- 
ly, as  much  lessened  as  possible,  by  frequently  touching  and 
moving  them  about  with  the  finger.  This  should  be  done 
several  times  a  day,  for  at  least  two  weeks  before   the  ope- 


*  We  are  informed  by  Velpeau,  in  his  Elements  of  Operative  Surgery,  p.  428, 
that  M.  Colombo  performed  the  operation  on  a  dead  subject  in  1813,  and  in  1815 
endeavored  to  prevail  on  a  patient  to  permit  him  to  repeat  it,  but  without  success. 
In  1817,  too,  M.  Graefie  published  in  Hufeland's  Journal  some  details  concerning 
it,  but  the  subject  elicited  no  interest  until  ^1.  Roux  performed  the  operation  in 
1819. 

t  Vide  Dr.  Reese's  Appendix  to  Cooper's  Surgical  Dictionary. 


STAPHYLORAPHY. 


857 


ration  is  attenii^ted,  and  during  this  time,  the  patient  should 
he  restricted  to  a  spare  diet. 

The  operation  of  staph  yloraphy,  or  velosynthesis,  consists 
in  removing  the  margins  of  the  divided  velum  witli  a  pair 
of  curved  scissors,  as  recommended  hy  M.  Eoux,  or  a  dou- 
hle-edged  knife,  and  holding  the  raw  edges  in  contact  with 
each  other  until  a  union  takes  place. 

A  number  of  ingeniously  contrived  instruments  have  been 
invented  for  the  performance  of  the  operation,  but  all  that 
are  really  necessary,  are,  a  sharp  hook,  a  double-edged 
knife,  short  curved  needles,  a  needle-holder,  (po7ie-a{gu{lle,) 
strong  waxed  ligatures,  a  pair  of  long-handled  curved  for- 
ceps, and  scissors  ;  other  instruments  may,  in  some  cases,  be 
required.  In  addition  to  the  above,  water,  towels,  and  one 
or  more  assistants,  will  be  needed. 


Thus   prepared,    the    pa-  ^^^  ^48 

tient,  after  having  been  pre- 
viously submitted  to  the  ne- 
cessary preparatory  treat- 
ment, should  be  placed  in  a 
chair  facing  a  good  light, 
with  his  head  firmly  support- 
ed by  an  assistant,  and  his 
mouth  open ;  the  operation 
m  ly  be  commenced  by  in- 
serting the  hook  into  the 
the  margin  of  the  velum, 
near  its  most  dependent  part, 
on  the  left  side  of  the  fissure, 
in  the  manner  as  represent- 
ed in  Fig.  248.  This  instrument,  held  by  an  assistant, 
should  be  depressed  so  as  to  make  the  margin  slightly  tense 
The  point  of  the  double-edged  knife  may  now  be  placed  be- 
low the  most  dependent  part  of  the  velum,  a  little  to  the 
left  of  where  the  hook  is  inserted,  (see  Fig.  248,)  and  carried 
from  below  upwards  until  it  has  reached  the  angle  of  the 
55 


858 


STAPIIYLORAPHY. 


Fig.  249. 


fissure,  removing  about  one  line  of  the  margin.     'I'liis  ope- 
ration may  be  repeated  on  the  opposite  side  of  the  fissure,  or 

by  changing  the  knife  from 
the  right  to  the  left  hand, 
ami  directing  the  assistant 
holding  the  hook  to  pass 
his  hand  "across  and  a 
little  above  the  face  of  the 
patient,"  in  tlie  manner  as 
described  by  Dr.  Miitter, 
^o  as  to  keep  up  a  constant 
traction  ii})on  the  strip  of 
mucous  membrane  remov- 
ed by  the  first  cut,  the 
right  margin  of  the  fissure 
may  be  made  tense,  and 
the  knife  carried  from 
above  downwards^  com- 
pleting, by  a  single  inci- 
sion, the  whole  of  this 
part  of  the  operation. 


Further  procedure  shou 
be  suspended  until  th 
hemorrliage,  though  sel- 
dom very  great,  shall  have 
partially  subsided.  A  nee- 
dle, armed  with  a  well 
waxed  ligature,  and  held 
in  a  pair  of  suitable  for- 
ceps, should  be  passed 
from  beiure  backwaids  through  the  most  dependent  part  <• 
the  left  margin,  about  three  lines  from  the  edge.  As  soni 
as  it  is  seen  on  the  opposite  side,  it  should  be  grasped  by  th' 
assistant  with  a  pair  of  longhandled  forceps,  and  as  soon  as 
the  hold  of  the  porte-aiguille  is  relaxed,  drawn  through,  re- 
placed in    the  latter,  and  passed  through,  from  behind  for- 


i 


STAPHYLOKAPnY. 


859 


wards,  the  right  margin  of  the  velum  opposite  to  the  lig- 
ature in  the  left.  See  Figs.  249,  250.  After  the  patient 
has  rested  a  few  minutes,  a  second,  thirds  and,  when  neces- 
sary, a  fourth  ligature  should  be  introduced. 


Fia.  252 


The  passage  of  the  nee-  ^'°-  ^si 

die  through  the  left  margin 
of  the  velum  is  represented 
in  Fig.  249,  and  in  Fig. 
250,  through  the  right  mar- 
gin from  behind  forwards. 

The  ligature  first  intro- 
duced should  now  be  tied, 
bringing  the  edges  of  the 
velum  close  together^  and, 
afterwards^  the  second  and 
third,  cutting  off  the  ends 
of  each.  After  the  first 
knot  of  the  ligature  is  tied, 
some  precaution  should  be 
used  to  prevent  this  from 
slipping,  while  the  second 
is  tied.  The  method  adopt- 
ed by  M.  Roux  for  knot- 
ting the  ligature  is,  to  make 
the  first  fold  of  the  knot 
with  the  fore-finger  of  each 
hand  placed  back  to  back, 
and  after  this  has  been 
drawn  sufiiciently  tight,  it 
is  seized  by  an  assititant 
with  a  pair  of  forceps,  and 
held  until  the  second  and 
last  turn  of  the  knot  is 
made. 

Some  surgeons  use  two  needles  for  each  ligature- 
each  end,  and  introduce  them  from    beliind   forward 


-one  at 
.s — one 


860 


STAPHYLORAPHY. 


through  each  margin  of  the  divided  velum,  instead  of  one, 
as  in  the  method  just  described. 

The  following  cut,  Fig.  253,  copied  from  Liston's  and 
Mutter's  Surgery,  represents  the  needle-holder,  or  "porte," 
of  Schwcrdt,  which  is,  perhaps,  as  well  adapted  to  the  pur- 
pose as  any  instrument  that  can  be  employed.  Dr.  Physic's 
forceps  have  also  been  used,  but  Dr.  Mutter  thinks  this  a 
preferable  instrument. 

Fig.  253. 


After  the  operation  has  been  performed,  the  patient  should 
be  directed  to  keep  his  mouth  closed,  maintain  perfect  quiet; 
avoid  coughing,  sneezing,  or  even  spitting,  and  the  use  of 
all  solid  food.  Nor  should  he  take  but  very  little  aliment, 
and  this  only  at  long  intervals.  For  appeasing  the  cravings 
of  the  hunger  with  which  some  suflfer,  Dr.  Mutter  recom- 
mends "thin  calf  s-foot  jelly,  or  what  is  known  as  cold  cus- 
tard slip,"  as  the  best  nourishmeht  that  can  be  used,  but 
he  thinks  neither  should  be  given  until  after  the  second  or 
third  day  after  the  operation  has  been  performed. 

In  the  performance  of  the  operation  of  staphyloraphy, 
however,  different  surgeons  employ  different  instruments, 
and  adopt  different  methods  of  procedure.  Professor  N.  R. 
Smith,  of  Baltimore,  who  has  performed  the  operation  five 
times,  and  in  three  cases  with  perfect  success,  employs  a 
very  simple  needle,  of  a  lance  shape,  mounted  on  a  handle, 
and  having  a  slit  near  its  point  which  opens  at  its  posterior 
end.  The  needle  is  broader  in  front  of  this  eye  than  behind 
it,  which  renders  the  passage  of  the  back  part  more  easy. 
Armed  with  a  ligature,  the  curved  portion  of  the  needle  ii^ 
carried  beyond  the  fissure,  and  its  point  introduced  "behinc 
the  middle  of  the  uvula,"  and  as  soon  as  it  has  come  througl 
far  enough  to  expose  the  ligature  in  the  slit,  it  "is  taker 


STAPHYLORAPHY.  861 

hold  of  with  a  tenaciiluin,  disengaged  from  the  slit  or  eye 
in  the  needle,"  when  ''the  latter  instrument  is  withdrawn." 
A  second  ligature,  in  like  manner,  is  introduced  "half  an 
incli  liiglier  up,"  and  a  third,  if  necessary,  "at  an  equal 
distance  from  the  second.  With  the  ends  of  the  ligature 
passed  through  the  uvula,  this  part  is  drawn  forwards," 
until  the  fissure  in  the  soft  plate  shall  assume  nearly  a 
"horizontal  position,"  its  edges  are  then  cut  off  with  a  "pair 
of  scissors,  either  straight  or  curved  laterally,"  or  with  a 
histoury  and  a  pair  of  forceps.  This  done,  the  ligatures  are 
tied,  and  the  ends  cut  off.* 

Dr.  J.  C.  Warren,  of  Boston,  who  has  performed  the 
operation  a  number  of  times,  uses  a  needle  of  his  own  inven- 
tion, with  a  movable  point.  Dr.  J.  M.  Warren,  son  of  Dr. 
J.  C. ,  has  also  performed  the  operation  a  number  of  times,  and 
with  very  great  success.  When  it  extends  up  into  the  liard 
palate,  he  dissects  the  mucous  membrane  from  the  bones  on 
each  side  of  the  fissure,  carrying  his  knife  sufSciently  for- 
ward towards  tlie  alveolar  border,  to  form  a  flap  broad 
enough  to  meet  a  like  one  from  the  opposite,  along  the 
median  line. 

Dr.  HuUihen,  who  has  performed  the  operation  several 
times,  has  invented  a  very  ingenious  needle-holder,  wliich, 
we  have  no  doubt,  will  ultimately  supersede  the  use  of  most 
others. t 

Wlien  the  fissure  is  so  wide  as  to  prevent  the  margins  of 
the  velum  from  being  brought  together.  Dr.  Mettauer,  of 
Virginia,  recommends  making  several  lateral  incisions 
through  the  mucous  membrane,  with  a  view  to  increase  the 
extent  of  the  velum,  and  thus  permit  their  edges  to  be 
brouglit  together.  Mr.  Fergusson  proposes,  for  the  more 
easy  and  perfect  accomplisliraent  of  this  end,  the  division  of 
the  levator-palati,  tlie  palato-pliaryngeus,  and  the  palato- 

*  Vide  Appendix  to  Cooper's  Surjjical  Dictionary,  by  Dr.  Reese,  p.  12G. 

t  A  description  of  this  instrument,  together  with  Dr.  Uullihen's  method  of  per- 
forming the  operation,  is  given  in  vol.  5th,  of  the  American  Journal  of  Dental 
Science. 


862 


STAPHYLORAPHY. 


Fig.  254. 


glossus  muscles.  The  iiiotory  influence  of  the  muscles,  in 
an  upward,  outward  and  downward  direction,  being  thus, 
for  a  time,  cut-off,  lie  believes  the  motory  power  of  the  soft 
palate  will  be  so  mucii  destroyed,  that  the  edges  of  the 
fissure  may  be  brought  together.* 

For  supplying  deficiency  of 
structure,  Dieffenbach  recom- 
mends a  longitudinal  incision 
a  short  distance  from  the  mar- 
gin of  the  fissure,  in  the  man- 
ner as  seen  in  Fig.  254, 
copied  from  Dr.  Pancnast's 
Operative  Surgery.  The  last 
named  gentleman  has  y)er- 
formed  the  operation  in  two 
cases,  with  success.  Dr. 
Mutter,  of  Philadelphia,  who 
has  been  very  successful  in 
^^"  ^  the  operation,   has  also  had 

recourse  to  these   latei-al    longitudinal  incisions,   with  the 
most  happy  results. f 

When  the  inflammation  which  follows  the  operation  is 
very  severe,  it  sliould  be  combated  by  general  and  local 
bleeding,  and  such  other  antiphlogistic  means  as  the  nature 
of  the  case  may  seem  to  demand.  When  the  inflammation 
is  accompanied  by  cough.  Dr.  Mutter  recommends  the  ad- 
ministration of  opiates.  The  same  author  recommends,  in 
case  sloughing  of  the  parts  takes  place,  the  a})plication, 
with  a  camel's-hair  pencil,  of  a  solution  of  the  nitrate  of 
silver,  or  a  mixture  of  creosote  and  water,  "three  or  four 
times  a  day." 

It  often  happens,  that  an  opening  remains  in  tlie  palate 
after  the  velum  has  been  successfully  united.  This  may 
sometimes  be  closed  by  the  granulation  of  the  edges  of  tlie 


*  Vide  Medico-Chirurgical  Transactions,  vol.  28. 
I  Vide  Liston's  and  Miitter's  Surgery,  p.  204. 


STAPHYLORAPHY. 


863 


cleft,  which  may  be  induced  by  making  them  raw  by  the 
application  of  caustic  or  the  actual  cautery.  DiefTenbach 
has  employed,  with  success,  a  concentrated  tincture  of  can- 
tharides,  applied  several  times  a  day  to  the  edges  of  the 
opening.*  By  some,  the  actual  cautery  is  preferred,  but  if 
the  latter  be  used,  it  should  only  be  heated  sufficiently  to 
blister  the  parts. f  The  nitrate  of  silver  and  potassa  pura 
have  been  used,  but  there  is  danger  of  causing  a  greater  loss 
of  substance  by  the  use  of  these  powerful  caustics  than  can 
be  gained  by  the  granulations  which  they  induce. 

A  surgical  operation  is  sel-  Fig.  255. 

dora  performed  for  the  pur- 
pose of  closing  a  simple  open- 
ing in  tlie  hard  palate.  It 
has  been  recommended,  how- 
ever, by  some  surgeons,  and 
when  the  hole  is  not  very 
large,  the  operation  of  sta- 
pliyloplasty  may  be  success- 
fully performed.  In  Fig.  255, 
copied  from  Dr.  Pancoast's 
Operative  Surgery,  the  opera- 
tion as  performed  by  the 
author  of  this  valuable  work, 
is  represented,  and  so  per- 
fectly is  it  exhibited  in  the  cut,  that  we  do  not  deem  any 
further  description  necessary.  In  the  majority  of  cases  of 
this  kind,  however,  an  artificial  obturator  or  palate  will  be 
found  necessary. 


*  Vide  British  and  Foreign  Medical  Review,  for  April,  1846. 

t  Vide  Dr.  Hullihen  on  Cleft  Palate,  in  Am.  Jour.  Deut.  Science,  vol  5,  p.  173. 


864 


ARTIFICIAL   OBTURATORS   AND   PALATES. 


ARTIFICIAL  OBTURATORS  AXD  PALATES.* 

Although  by  the  operation  of  staphyloraphy,  the  use  of 
mechanical  contrivances  for  remedying  imperfections  of  the 
palate,  are  often  rendered  unnecessary,  yet,  in  the  majority 
of  cases,  it  is  only  by  such  means  that  any  relief  can  be 
afforded.  Artificial  palates  and  obturators  have  been  em- 
ployed for  a  long  time. 

They  were^  according  to  Guillemean,  applied  by  the  Greek 
physicians,  but  it  is  to  that  celebrated  French  surgeon, 
Ambrose  Pare,  that  we  are  indebted  for  the  first  description 
of  an  appliance  of  this  sort.  This  author  has  furnished  an 
engraving  of  an  obturator  which  he  had  constructed  in 
1585,  consisting  of  a  metallic  plate,  probably  of  silver  or 
gold,  fitted  to  an  opening  in  the  vault  of  the  palate.  It  was 
held  up  by  means  of  a  piece  of  sponge,  fastened  to  a  screw- 
in  an  upright  attached  to  the  upper  surface  of  the  plate. 

The  employment  of  sponge,  however,  was  found  to  be  objec- 
tionable, as  the  secretions  of  the  nasal  cavities  which  it  ab- 
sorbed, soon  became  insufferably  offensive,  but  notwithstand- 
ing, it  continued  to  be  used  for  a  long  time.  Ultimately, 
however,  it  was  superseded  by  an  obturator  invented  by  Fau- 
chard.  This  was  held  up  by  means  of  wings,  which  turned  on 
a  pivot.  Both  of  tliese  obturators,  however,  exerted  a  hurt- 
ful influence  upon  the  surrounding  parts^  as  the  pressure 
produced  by  the  sponge  and  wings  caused  them  to  be  grad- 
ually destroyed,  and  thus  augmented  the  evil  they  were  de- 
signed to  remedy,  consequently,  their  use  has  been  wholly 


*  Although  a  distinction  is  made  by  some  writers,  between  the  terms  artificial 
palate  and  palatine  obturator,  there  does  not  seem  to  be  much  propriety  in  it, 
since  they  both  sijjnify  one  and  the  same  thing,  namely,  an  instrument  to  close  or 
atop  an  opening  in  the  palate.  The  former  term,  however,  is  generally  applied 
to  a  simple  plate  fitted  to  the  palatine  arch,  the  latter,  to  a  plate  surmounted  by 
apiece  of  sponge,  wings,  or  a  drum  or  air  chamber,  passing  up  into  or  through 
the  opening,  iind  desiuned  either  to  hold  up  the  plate,  or  to  fill  the  aperture. 
When  a  velum  is  attached,  the  instrument  is  termed  an  artificial  palate  with  a 
velum. 


ARTIFICIAL   OBTURATORS  AND   PALATES.  865 

abandoned.  We  do  not,  therefore,  deem  it  necessary  to  give 
a  description  of  either.  We  will,  however,  quote  a  passage 
from  Bourdet  upon  the  subject.  In  alluding  to  the  impro- 
priety of  having  recourse  to  any  appliance  which  has  a  ten- 
dency to  counteract  the  curative  efforts  of  nature,  he  says, 
"Before  considering  the  cicatrised  perforations  of  the  palate 
as  being  of  a  nature  incapable  of  diminishing  in  diameter, 
practitioners  should  satisfy  themselves  properly  and  beyond 
doubt,  that  such  is  the  case.  We  do  not  think  so,  for  pos- 
itive facts  attest  the  contrary,  and  as  holes  made  in  the 
cranium  with  the  trepan  closed  almost  entirely^  in  like  man- 
ner, those  of  the  palate  constantly  diminish."  Numerous 
examples  might  be  adduced  if  it  were  necessary  to  prove  the 
impropriety  of  sustaining  an  obturator  by  any  fixtures 
which  act  upon  the  lateral  parts,  as  they  necessarily  tend  to 
increase  the  dimensions  of  the  opening  in  the  palate.  Cases 
do,  however_,  sometimes  occur,  in  which  no  other  means  of 
support  are  offered,  and  then  the  dentist  may,  perhaps,  be 
justifiable  in  using  them. 

With  a  view  of  obviating  the  objections  which  have  been 
mentioned  as  existing  to  the  obturators  of  Pare  and  Fau- 
chard,  Bourdet  proposed  to  employ  simply  a  metallic  plate, 
fitted  to  the  vault  of  the  palate  and  large  enough  to  cover 
the  opening,  with  two  lateral  prolongations,  one  on  each 
side,  extending  to  the  teeth,  to  which  they  were  fastened  by 
means  of  ligatures.  This  was  also  found  to  be  objectiona- 
ble, as  the  ligatures  were  productive  of  constant  irritation 
to  the  gums,  and  besides  they  did  not  hold  the  plate  with 
sufficient  stability  in  its  place.  Its  use  was,  therefore,  soon 
abandoned.  But  these  objections  were  both  obviated,  as  we 
have  stated  in  another  place,  by  an  improvement  made  by 
M.  Delabarre,  wliich  consists  in  the  employment  of  clasps^ 
instead  of  ligatures  attached  to  lateral  branches  of  the  plate, 
and  to  prevent  these  from  slipping  too  high  up  upon  the 
teetli,  he  attached  to  each  a  kind  of  spur,  which  was  so  bent 
as  to  come  down  over  the  grinding  surface  of  the  one  to 
which  it  was  applied.     The  last  named  author,  also,  made 


866  ARTIFICIAL   OBTURATORS    AND    PALATES. 

another  equally  valuable  improvement,  wbicli  consisted  in 
the  application  of  a  drum  to  the  upper  surface  of  the  plate. 
The  object  of  this  was  to  prevent  the  accumulation  of  mucous 
fluids  from  the  nose,  in  the  cul-de-sac,  formed  by  simply 
closing  the  opening  below,  and  to  prevent  fluids,  in  swal- 
lowing, from  passing  up  between  the  obturator  and  soft 
parts,  through  the  opening  into  the  nose. 

The  manner  of  constructing  an  obturator,  with  a  drum 
upon  its  upper  surface,  is  as  f(L)llows :  First  take  an  impres- 
sion of  the  entire  palatine  vault  and  alveolar  ridge  in  wax. 
From  this,  a  plaster  and  metallic  model  and  a  coimter-model 
are  procured,  in  the  manner  as  before  described  ;  a  gold 
plate  is  then  swaged  between  the  two  last,  a  little  larger 
than  the  opening  in  the  palate,  with  a  broad  arm  on  each 
side,  extending  to  a  bicuspid  or  molar  tooth,  to  which  a 
broad  clasp  is  fitted.  This  is  soldered  to  the  arm  fi-om  the 
plate.  Second,  an  impression  of  the  opening  in  the  vault 
of  the  palate  with  wax,  properly  softened  and  placed  upon 
the  upper  surface  of  the  palate  plate,  is  now  taken,  using 
the  precaution  to  prevent  forcing  it  up  too  far  through  the 
aperture;  this  is  next  trimmed  where  it  comes  in  contact 
with  the  plate,  so  that  it  shall  not  be  quite  as  large  as  the 
opening;  it  is  then  covered  with  plaster,  after  which  a  me- 
tallic model  and  counter-model  is  taken,  then  a  gold  plate 
is  swaged  between  the  two,  and  this  last  is  fitted  and  sol- 
dered to  the  palatine  plate.  The  piece  after  being  properly 
finished,  is  now  ready  to  be  a])plied. 

It  is  of  the  greatest  importance  tliat  an  artificial  palate  or 
obturator  should  be  executed  in  the  most  ])erfect  manner, 
and  be  made  to  fit  accurately  to  all  tlie  parts  with  which  it 
is  to  be  in  contact,  so  tliat  it  may  not  produce  the  slightest 
irritation  or  exert  undue  pressure  upon  any  of  the  super- 
jacent or  surrounding  parts.  As  in  the  case  of  the  applica- 
tion of  a  dental  substitute,  the  piece  should  not  be  applied 
while  any  of  the  teeth,  especially  those  of  the  upper  jaw,  are 
in  an  unhealthy  condition.  The  gums  and  sockets  of  the 
teeth  should  also  be   free  from  disease.     The   piece,  too, 


PALATE  PLATE,  OR  PALATINE  OBTURATOR. 


867 


sliould  be  removed  two  or  three  times  every  day,  and  thor- 
ouglily  cleansed,  as  also  the  teeth  to  which  the  clasps  are 
applied. 

A  SIMPLE  PALATE  PLATE,  OR  PALATINE  OBTURATOR. 


When  the  opening  in  the  ^'°-  ^^e. 

palate  is  small  and  hasnocon- 
nection  with  the  velum,  it  is 
seldom  necessary  to  raise  the 
upper  surface  of  the  plate  by 
attaching  a  drum  or  air- 
chamber  to  it.  If  it  be  accu- 
rately fitted  to  the  vault  of 
the  palate,  it  will  effectually 
prevent  fluids  in  deglutition 
from  passing  up  into  the  nasal  cavities,  or  the  escape  of  any 
portion  of  the  voice  through  the  opening,  and  by  frequently 
reuioving  the  plate,  it  will  prevent  the  stagnation  of  the 
secretions  which  may  accumulate  in  the  cul-de-sac.  A 
simple  plate  like  the  one  represented  in  Fig.  256,  will  be  all 
that  is  required  to  remedy  the  defect. 

Although  the  stability  of  the  plate  will  very  much  depend 
upon  the  width  of  the  clasps,  the  latter  should  never  be  so 
wide  as  to  press  upon  the  gums  around  the  necks  of  the 
teeth  to  which  they  are  applied,  as  in  that  case  they  will  be 
productive  of  irritation,  and  ultimately  cause  the  destruc- 
tion of  the  alveoli  and  loss  of  the  teeth.  Nor  should  they 
press  upon  the  teeth  so  as  to  force  them  apart  or  draw  them 
towards  each  other,  as,  in  cither  case,  the  effect  would  be, 
gradually  to  loosen  and  displace  the  organs.  In  short,  the 
same  precautions  arc  necessary  in  the  api)lication  of  clasps 
to  a  palate  plate,  as  to  one  which  is  to  serve  as  a  support  for 
artificial  teeth. 


868         A   PALATE    PLATEj    OR    OBTURATORj    AVITII    A    DRUM. 


A  PALATE  PLATE,  OR  OBTURATOR,  WITH  A  DRUM  UPON  ITS  UP- 
PER OR  CONVEX  SURFACE. 


^"'-  2  57.  j^n  obturator  of  this  des- 

cription is  seldom  required, 
except  iu  those  cases  where 
the  opening  in  the  palate  is 
connected  with  the  velum, 
so  that  by  the  contraction 
of  its  muscles,  the  parts  are 
raised  fi-om  the  plate  in 
such  a  manner  as  to  permit 
fluids,  in  the  act  of  deglu- 
tition, to  pass  up  into  the  nose.  In  this  case  it  will  not  only 
prevent  this  difficulty,  but  it  will  also  prevent  the  fluids  of 
the  nose  from  accumulating  in  the  opening  above  the  plate. 
As  the  manner  of  constructing  an  obturator  of  this  des- 
cription, (see  Fig.  257,)  has  been  already  described,  it  will 
only  be  necessary  to  add,  that  in  fitting  and  adjusting  the 
drum  to  the  upper  surface  of  the  plate,  great  care  is  neces- 
sary to  prevent  placing  it  to  one  side  of  the  oj)ening. 
After  it  has  been  properly  adjusted  and  one  side  of  it  sol- 
dered to  the  palate  plate,  a  hole  should  be  drilled  through 
it  for  the  escape  of  the  heated  air,  while  the  remainder  of 
the  soldering  is  effected.  Tliis  done,  the  whole  may  be 
closed  by  the  introduction  of  a  screw  of  tlie  same  metal, 
which  may  afterwards  be  filed  off  even  with  the  surface  of 
the  plate. 

In  the  construction  of  an  obturator,  like  cither  of  the  fore- 
going, but  little  ingenuity  or  artistical  skill  is  required,  as 
the  mechanism  is  of  the  simplest  description.  The  adapta- 
tion_,  however,  should  be  perfect,  and  the  execution  neat. 
The  gold  should  also  be  sufficiently  fine  to  prevent  being 
acted  upon  by  the  secretions  of  the  buccal  or  nasal  cavities. 


ARTIFICIAL   PALATE,    VELUM   AND   UVULA.  869 


AN  ARTIFICIAL  PALATE,  WITH  A  VELUM  AND  UVULA. 

It  sometimes  happens,  in  cases  of  congenital  fissure  of  the 
palate^  that  the  margins  of  the  velum  are  so  far  apart  as  to 
preclude  the  possibility  of  uniting  them  by  any  surgical 
operation,  and,  at  other  times,  these  parts  are  wholly  de- 
stroyed by  ulceration  ;  it  is  in  such  cases,  that  an  artificial 
velum  is  required,  and  to  supply  which,  the  ingenuity  of 
art  has  been  taxed  to  its  fullest  extent.  Various  descrip- 
tions of  mechanism  have  been  invented  for  this  purpose, 
and  it  is  scarcely  necessary  to  say,  that  until  quite  recently, 
none  have  been  constructed  which  has  performed,  to  any 
very  considerable  extent,  the  functions  of  the  natural  parts. 
Nor  has  this  desirable  object,  even  yet,  been  very  fully 
accomplished,  but  one  of  the  most  ingenious  contrivances  of 
the  kind  which  has  ever  been  invented,  was  recently  con- 
structed by  Mr.  Stearns,  surgeon,  of  London.  The  principle, 
however,  upon  which  it  acts,  was  not  altogether  original,  as 
M.  Delabarre,  had  previously  constructed  a  piece  of  mechan- 
ism somewhat  similar  to  it^  and  composed  of  the  same, 
though  of  a  less  perfect  material. 

The  contrivance  employed  by  Delabarre,  consisted  of  a 
metallic  plate,  bent  in  the  form  of  a  horse-shoe,  and  occu- 
pied the  place  of  the  posterior  part  of  the  naso-palatine 
floor  ;  the  nasal  portion  was  grooved  for  the  reception  of  the 
vomer.  The  palatine  surface  was  concave,  and  made  to  re- 
semble the  vault  of  the  palate.  From  each  side  of  this,  an 
arm  projected  to  the  first  molar,  to  which  it  was  secured  by 
means  of  a  clasp.  To  the  posterior  portion,  a  piece  of 
caoutchouc,  resembling  in  shape  the  form  of  the  velum  and 
uvula,  was  attached.  Although  this  instrument  is  repre- 
sented as  having  performed  all  the  functions  of  the  velum, 
so  far  as  deglutition  and  speech  are  concerned,  we  arc  dis- 
posed to  doubt  the  correctness  of  the  statement  to  its  full 
extent,  as  it  has  failed  to  do  so  in  other  cases   in  which  it 


870  ARTIFICIAL   PALATE,    VELUM   AND   UVULA. 

has   been  a2)pliecl,    though    much  advantage,    in  some  in- 
stances, has  certainly  been  derived  from  it. 

The  instrument  constructed  by  Mr,  Stearns,  consists  of  a 
plate  of  gold,  fitted  to  the  vault  of  the  palate,  in  the  usual 
manner^  and  to  the  upper  and  ])Osterior  margin  of  which,  is 
attached  a  flat  spiral  spring,  admitting  of  easy  vibrations 
backwaids  nnd  forwards  ;  to  the  posterior  extremity  of  this 
is  attaclied  a  flexible  velum,  "constructed  of  Mr,  Goodyear's 
preparation  of  caoutchouc^  which,"  says  Mr,  Stearns,  has 
"the  property  to  resist  the  action  of  both  oils  and  acids,  and 
at  the  same  time  sustaining  a  high  degree  of  heat,"  Desig- 
nating the  principal  parts  of  the  instrument  by  the  name  of 
body  and  wings,  Mr.  S.  remarks,  "The  body  of  the  velum 
consists  of  the  lamina  of  caoutchouc,  of  a  somewhat  tri- 
angular form,  and  of  the  same  size  and  shape  as  the  vacant 
space  it  is  intended  to  occu])y,  that  being  the  place  wliich 
would  be  indicated  by  imaginary  lines,  connecting  the  oppo- 
site sides  of  the  columns,  and  subtending  the  vertical  angle 
of  the  fissure,  at  which  point  the  velum  is  connected  to  the 
jDOsterior  extremity  of  the  spiral  spring.  The  lamina,  con- 
stituting the  body  of  the  velum,  is  divided  into  three  pieces, 
which  overlap  each  other.  The  wings  project  obliquely 
forwards  and  outwards  from  each  lateral  margin  of  the  body, 
and  being  made  to  conform  to  the  shape  of  the  columns  or 
sides  of  the  fissure,  are  seen  to  rest  upon  their  inner  and 
anterior  surfaces,  thus  covering  a  portion  of  the  soft  parts 
which  constitute  the  boundaries  of  the  posterior  fauces.  In 
like  manner,  along  each  lateral  margin  of  the  body,  there 
is  (in  mechanical  phrase,)  a  flange,  projecting  obliquely, 
backwards  and  outwards,  and  extending  along  down  the 
posterior  surface  of  the  column,  it  terminates  at  the  inferior 
angle  of  the  velum.  In  this  way  the  wing  and  flange,  on 
the  same  side,  together  form  a  groove  fitted  to  receive  the 
fleshy  sides  of  the  fissure.  As  the  preparation  of  caoutchouc 
made  use  of,  presents  a  smooth  surface,  and  yields  readily  to 
the  slightest  pressure,  it  is  found  to  permit  the  contact  and 
muscular   action   of  the   surrounding  soft   parts,    without 


ARTIFICIAL   PALATE,    VELUM   AND   UVULA. 


871 


Fig.  258. 


causing  any  irritation.  When,  therefore,  the  sides  of  the 
fissure  tend  to  approximate,  as  in  deglutition,  gargling  the 
throat,  or  the  utterance  of  some  of  the  short  vowel  sounds, 
the  three  parts  of  the  body  of  the  velum  slide  readily  by 
each  other,  thus  diminishing  the  extent  of  exposed  surface, 
and  thereby  imitating,  to  some  extent,  muscular  contractile 
action,  the  force  being  derived  from  without,  and  not,  of 
cour.se,  contained  within  the  instrument.  During  the  effort 
made  in  speaking,  the  surrounding  muscular  parts  embrace 
and  close  upon  the  artificial  velum,  and  press  it  back  against 
the  concave  surface  of  the  pharynx.  The  passage  to  the 
nares  being  therefore  temporarily  closed,  the  occlusion  of 
sound  is  accomplished,  and  articulation  made  attainable,  as 
tlie  voice  or  sound,  as  it  issues  from  the  glottis,  is  thereby 
directed  into  the  cavity  of  the  fauces,  and  confined  there 
long  enough  to  receive  the  impressions  made  upon  it  by  the 
tongue,  lips,  etc. ,  in  the  formation  of  the  consonant  letters." 

A  velum  constructed  after  the 
foregoing  manner,  Mr.  Stearns 
thinks,  will  be  found  applicable 
in  all  cases,  though  it  will  be 
necessary  in  the  construction  of 
the  palate  plate,  to  give  it  such 
form  and  dimensions  as  may  be 
required  by  the  peculiarities  of 
each  case.  For  example,  when 
the  fissure  extends  through  the 
alveolar  border,  or  when  some  of 
the  front  teeth  are  wanting,  it 
will  be  necessary  to  extend  it 
sutficiently  forward  to  close  the 
opening,  or  serve  as  a  base  for 
such  dental  substitutes  as  may  be 
required. 

Through  the  courtesy  of  Dr.  E.  G.  Tucker,  of  Boston,  we 
are  enabled  to  add  to  the  foregoing  description,  an  engraving 
of  the  instrument,  made  from  a  duplicate,  which  he  sent  to 


872 


ARTIFICIAL  PALATE,    VELUM   AND   UVULA. 


US  since  the  publication  of  the  fourth  edition  of  this  work, 
of  one,  which  he  and  his  brother^  Dr.  J.  Tucker^  constructed. 
In  the  annexed  cut  is  seen  the  lower  surface  of  the  palate 
plate  and  anterior  surface  of  the  velum,  a,  the  palatine 
plate  ;  b,  the  flat  spiral  springs,  extending  from  the  posterior 
margin  of  the  plate  to  the  upper  part  of  the  velum  ;  c  c, 
wings  of  the  velum  ;  d  d,  the  flange  ;  e,  the  central  portion. 
See  Fiar.  258. 


Fio.  259. 


Fig.  260. 


FiQ.  261. 


Fig.  259  shows  the  upper  surface 
of  the  palate  and  the  posterior  sur- 
face of  the  velum  and  spiral  springs. 
a,  palate  plate  ;  b,  spiral  springs  ; 
c  c,  wings  of  the  velum  closed  ;  d  d, 
the  flange  as  seen  above  the  wings, 
and  e,  the  central  portion  below  the 
wings,  and  intended  to  rej)resent 
the  uvula. 

Fig.  2G0.  The  velum  with  the  wings  separate,  showing 
the  central  portion,  before  being  attached  to  the  hook,  at 
the  lower  extremity  of  the  flattened  spiral  springs.  In  Fig. 
261_,  is  represented  a  side  view  of  the  velum,  showing  the 
groove  between  tlie  flange  and  the  wings,  for  the  reception 
of  the  fleshy  sides  of  the  fissure. 

With  a  view  of  restoring  the  air  passages  to  their  normal 
condition  in  those  cases  where  the  velum  has  been  lost  by 
disease,  Dr.  S.  P.  HuUihen  invented  an  instrument  consist- 
ing of  a  palate  plate  with  a  bi-globular  valve  attached  to  it 
in  such  a  manner  as  to  admit  of  the  egress  and  ingress  of 
the  desired  volume  of  air.     We  will  quote  from  vol.  1,  New 


ARTIFICIAL  PALATE,    VELUM   AND   UVULA.  873 

Series  of  the  American  Journal  of  Dental  Science,  the  des- 
cription which  Dr.  H.  has  given  of  the  instrument. 

"An  artificial  palate  made  upon  this  plan  will  be  com- 
posed of  four  parts  :  1st,  A  valve,  made  from  gold  plate,  as 
thin  as  it  can  well  he  worked  ;  2d,  A  spiral  spring  about  an 
inch  long,  and  of  the  size  usually  made  for  whole  sets  of 
teeth  ;  3d,  A  slider,  one  inch  and  a  half  in  length,  and  of 
the  width  and  thickness  of  a  common  watch  spring  ;  4th,  A 
plate,  larger  or  smaller,  as  the  case  may  require,  struck  up 
in  the  usual  way,  to  fit  the  roof  of  the  mouth. 

The  size  and  form  of  tlie  valve  is  obtained  by  taking  an 
impression  of  the  posterior  opening  of  the  nares  :  the  plate 
composing  it  should  be  struck  up  in  two  parts_,  front  and 
back,  which,  when  soldered  together,  makes  a  hollow  body 
of  the  form  in  Fig.  262,  letter  a.  At  the  upper  end  of  the 
valve,  a  small  pin  is  soldered,  the  point  of  which  looks 
downwards,  and  of  sufficient  thickness  to  fit  very  tightly  in 
one  end  of  the  spiral  spring.  The  spiral  spring  must  be 
made  of  such  a  length  as  will  permit  the  valve  to  rest 
slightly  upon  the  upper  surface  of  the  remnants  of  the  lost 
velum.  The  slider  has  a  pin  in  the  posterior  end,  looking 
upwards  to  receive  the  other  Fig.  262. 

end  of  the  spiral  spring- 
before  described.  The  an- 
terior end  of  the  slider  has 
a  small  button  looking 
downwards ;  the  slider  is 
attached  to  the  plate  by 
two  small  clasps,  as  repre- 
sented in  Fig.  263,  h  h. 
The  plate  may  be  made  to 
cover  the  entire  roof  of  the  mouth,  when  necessary  ;  or  it 
may  be  made  only  sufficiently  large  to  permit  the  mounting 
of  the  slider.  These  different  plates,  when  put  together, 
particularly  if  the  plate  is  to  cover  the  whole  roof  the  m  outh 
makes  a  plate  of  the  form  represented  by  Fig.  262. 

i56 


874 


ARTIFICIAL   PALATE,    VELUM   AND   UVULA. 


Fio-  263.  Fig.   2G3   shows  the 

attachment  of  the  spiral 
spring  to  the  valve  and 
slider,  c  c.  The  staples 
confine  the  slider  to  the 
plate,  b  h, — and  the  but- 
ton on  the  end  of  the 
slider,  d,  by  which  the 
valve  may  be  set  back 
or  forward,  as  desired  by  the  patient^  without  removing 
the  plate  from  the  mouth. 

The  plate  should  be  made  to  fit  the  several  parts  for 
which  it  is  intended,  with  great  exactness.  The  plate  must 
fit  the  roof  of  the  mouth,  and  the  teeth  to  which  it  may  be 
secured,  in  a  faultless  manner.  The  slider  must  be  arranged 
so  as  to  permit  the  valve  to  be  drawn  so  closely  against  the 
posterior  opening  of  the  nares,  as  to  close  them;  or  to  be 
pushed  back  so  as  to  leave  them  entirely  unobstructed.  The 
spiral  spring,  as  I  have  before  remarked,  must  be  made  of 
such  a  length  as  will  allow  the  valve  to  rest  slightly  upon  the 
upper  surface  of  the  remnants  of  the  lost  velum.  The 
valve  should  be  sufficientl}^  wide  at  its  base,  to  overlap  the 
remnants  of  the  velum  so  far  as  the  parts  on  each  side  will 
permit,  without  producing  irritation — any  other  part  of  the 
valve  than  the  base,  should  not  be  allowed  to  touch,  unless 
when  brought  forward  against  the  nares.  Unless  all  the 
parts  are  so  arranged,  the  palate  will  not  be  jiroperly  con- 
structed, and  will  not,  of  course,  answer  the  desired  end. 

"Thus  it  will  be  perceived,  that  the  peculiarities  of  this 
plate,  are,  firsts  a  valve  to  fit  the  posterior  opening  of  the 
nares.  Secondly,  the  attachment  of  this  valve  to  a  slider, 
by  which  the  patient  is  enabled  to  adjust  the  valve  while  in 
the  mouth,  in  such  a  way  as  to  admit  through  the  nares, 
just  the  quantity  of  air  desired.  Thirdly,  the  mounting  of 
the  valve  on  a  spiral  spring,  which  will  permit  it  to  vibrate 
backward  and  forward,  as  the  breath  is  inhaled  or  exhaled; 
and  also  to  be  moved  by  any  muscular  action  that  may  re- 


ARTIFICIAL  PALATE,    VELUM   AND   UVULA. 


875 


main  in  the  remnants  of  the  lost  velum,  tliereby  answering, 
to  a  great  extent_,  the  purposes  of  a  velum." 

All  the  benefit  which  it  is  possible  to  be  derived  from  an 
appliance  of  this  sort,  may,  in  the  majority'  of  cases,  we  be- 
lieve, be  secured  by  this  instrument.  We  met  with  one 
case,  however,  in  which  the  muscular  action  of  the  remains 
of  the  velum  against  the  valve  excited  so  much  irritation 
and  retching  that  it  could  not  be  worn.  To  obviate  which, 
Dr.  A.  A.  Blandy  constructed  a  palate  j^late  of  a  somewhat 
different  shape,  as  may  be  seen  from  Figs.  264,  265,  with  a 
valve  composed  of  two  pieces. 

To  the  posterior  edge  of  the  palate  plate,  another  plate  is 
soldered.  This  is  about  five-eighths  of  an  inch  in  width 
where  it  is  united  to  the  palate  plate,  and  half  an  inch  at 
the  posterior  extremity,  extending  upwards  and  backwards 
nearly  three-fourths  of  an  inch.  The  two  pieces  comj^osing 
the  valve  are  fixed  to  the  lower  surface  of  the  plate  in  such 
a  manner  that  the  contraction  of  the  remains  of  the  velum 
moves  them  towards  each  other.     But  with  their  relaxation 


Fig.  264. 


Fig.  265. 


they  are  immediately  separated  by  two  spiral  springs  at- 
tached to  the  upper  surface  of  the  palate  plate  at  one  end, 
and  to  two  delicate  springs  passing  tli rough  the  plate  united 
to  the  posterior  edge  of  the  first  mentioned  plate,  and  at- 


876  AETIFICIAL   PALATES   AND    OBTURATORS. 

tached  on  the  lower  surface,  one  to  each  part  of  the  valve. 
The  two  pieces  composing  the  valve  are  hollow,  each  about 
seven-eighths  of  an  inch  in  length,  and  of  a  conical  shape. 
The  bases  of  the  cones  are  placed  posteriorly  and  the  apices 
anteriorly.  The  surfaces  moving  on  the  plate  projecting 
from  the  palate  plate  are  flat,  and  the  outer  angle  of  the 
base  of  each  is  rounded.  But  the  several  parts  of  the  whole 
appliance  are  so  distinctly  shown  in  Figs.  264,  265,*  that 
we  do  not  deem  a  further  description  of  them  necessary.  In 
Fig.  264,  is  seen  a  lower,  and  in  Fig.  265,  an  upper  view  of 
the  apparatus,  which  has  been  worn  with  the  greatest  com- 
fort and  satisfaction  since  April  of  the  present  year,  1852. 
The  patient's  speech,  although  not  perfectly  restored,  is 
greatly  improved,  as  are  also  the  functions  of  mastication 
and  deglutition. 

ARTIFICIAL  PALATES  AND  OBTURATORS,  COMPLICATED  WITH  AR- 
TIFICIAL TEETH. 

When  an  imperfection  of  the  palate,  whether  the  result 
of  malformation  or  accident,  is  accompanied  by  the  loss  of 
one  or  more  teeth,  and  especially  from  the  anterior  part  of 
the  mouth_,  the  plate  which  is  employed  for  remedying  the 
former,  should  be  so  constructed  as  to  serve  as  a  base  for  a 
substitute  for  the  latter.  The  idea  of  complicating  a  palate 
plate  with  artificial  teeth,  as  the  author  has  stated  in  an- 
other place,  originated  with  Fauchard.  When  a  palatine 
obturator  and  artificial  teeth  are  to  be  applied  at  the  same 
time,  they  may  be  connected,  and  the  piece  made  to  answer 
an  excellent  purpose,  provided  there  be  healthy  and  natu- 
ral teeth  in  the  upper  jaw  to  sustain  it. 

In  the  construction  of  an  artificial  palate  or  obturator,  to 
which  artificial  teeth  are  to  be  attached,  a  gold  plate  of  the 
proper  size  should  be  fitted  to  all  that  portion  of  the  vault 
of  the  palate  and  alveolar  ridge  which  is  to  be  covered  by 

*  The  two  pieces  coaiposing  the  valve  are  purposely  separated  to  show  them 
more  distinctly. 


ARTIFICIAL   PALATES   AND   OBTURATORS. 


877 


,  witli  a  lateral  branch  on  each  side  extending  to  the  first 
lolar,  or  the  tooth  to  which  it  is  to  he  clasped.  To  tliese 
'asps  should  he  soldered^  and  Fio.  266. 

afterwards  artificial  teeth 
fitted  and  secured  in  the  man- 
ner as  described  in  part  sixth, 
t'  the  present  treatise.  If, 
liowever,  the  upper  surface  of 
the  plate  is  to  be  surmounted 
with  a  drum  or  air  chamber, 
this  should  be  done  before  the 
teeth  are  attached  to  it.  In 
Fig.  260,  may  be  seen  the 
engraving  of  a  simple  palate 
plate  or  obturator,  with  the  central  and  lateral  incisors 
attached  to  it. 

When  the  teeth  have  all  ^'^-  267- 

been  lost  on  one  side  of 
the  mouth,  or  are  too 
much  decayed  to  serve  as 
a  support  for  an  obturator, 
either  with  or  without  arti- 
ficial teeth,  the  plate  may 
be  constructed  with  two 
branches  upon  the  other 
side,  if  there  be  two 
healthy  and  firmly  articu- 
lated teeth,  to  which  clasps 
can  be  applied.  A  piece 
applied  in  this  manner,  in  connection  with  nine  artificial 
teeth,  namely,  the  four  incisors,  two  cuspidati,  two  bicus- 
pids, and  one  molar^  is  shown  in  Fig.  267.  The  clasps,  as 
may  be  perceived  by  the  cut,  are  intended  for  a  second 
bicuspid  and  second  molar.  Although  the  molars  on  the 
opposite  side  of  the  jaw  were  absent,  it  was  not  deemed 
prudent  to  increase  the  weight  of  the  piece,  by  attaching 
more  than  nine  artificial  teeth  to  the  plate. 


878 


ARTIFICIAL   PALATES  AND   OBTURATORS. 


^'°-  2^^-  An  artificial  palate,  com 

plicated  with  ten  artificial 
teeth,  namely,  the  centra': 
and  lateral  incisors,  the  cus- 
pidati,  the  first  bicuspid  ol 
the  left  side,  the  first  and 
second  of  the  right,  as  well 
as  the  first  molar,  is  repre- 
sented in  Fig.  268.  The 
clasps,  as  may  be  seen,  are 
for  the  first  molar  of  the 
left  side,  and  tlie  second  of 
the  right.  The  opening  in  the  palate  to  be  covered  by  the 
plate  in  this  case,  extended  from  the  alveolar  border  back- 
wards a  little  more  than  an  inch,  and  was  about  seven- 
eighths  of  an  inch  in  width. 

The  functions  of  mastication,  deglutition  and  speech, 
which  were  all  very  greatly  impaired  by  the  opening  in  the 
palate  and  loss  of  so  many  of  the  teeth,  were  all,  in  a  great 
degree,  restored  by  the  piece  here  represented. 


The  author  would  here  refer  to  an  obturator,  complicated 
with  artificial  teeth,  constructed  by  Mr.  Warren  Rowell,  of 
New  York,  and  the  great  difficulty  to  be  overcome  in  this 
case,  according  to  report  made  of  it  by  Dr.  Griscom,*  was 
the  want  of  teeth  in  the  upjK^r  jaw  to  sustain  it,  and  the 
great  size  of  the  opening  in  the  palate,  the  vomer  and  tur- 
binated bones  having  been  destroyed.  Upon  examination, 
however,  Mr.  Rowell  found  that  the  posterior  portion  of  the 
palatine  aperture  v.'as  formed,  ''to  a  considerable  extent,  of 
a  semi-cartilagiuons  substance,  possessing  sufficient  elas- 
ticity to  allow  a  larger  body  than  the  opening  to  be  pushed 
up  through  it,  and  that  when  so  forced  up,  it  would  be  sup- 
ported above  the  aperture  by  the  edge  retiring  to  its  origi-  ' 
nal  position."     This,  he  hoped,  would  support  a  light  plate,  | 


*  Vide  New  York  Journal  of  Medicine,  vol.  viii,  Xo.  23,  p.  187. 


ARTIFICIAL   PALATES   AND    OBTURATORS. 


879 


if  the  obturator  could  be  so  shaped  as  to  rest  upon  the  car- 
tilaginous ledge^  after  it  was  introduced. 

Without  quoting  the  description  which  is  given  of  his 
method  of  procedure,  it  will  be  sufficient  to  state,  that  the 
obturator,  which  he  constructed,  consisted  of  a  plate  larger 
than  the  opening  in  the  palate,  and  covering  the  anterior 
part  of  the  alveolar  ridge,  to  which  artificial  teeth  were 
attached,  and  an  irregularly  shaped  drum  or  air  chamber, 
larger  above  than  below,  where  it  was  connected  with  the 
palate  plate.  The  neck  of  this  bulb  or  drum,  is  of  the  exact 
size  of  the  opening  in  the  palate^  and  the  upper  part  or 
summit  has  several  depressions,  which  correspond  with  the 
irregular  "surfaces  of  the  remaining  nasal  bones." 


Fia.   269. 


Fig.  270. 


"'^-Aj^miiiJ.jiMiX-: 


The  anterior  part  of  the  palate  plate,  to  which  tlie  teeth 
are  attached,  as  maybe  seen  in  Fig.  269^  is  composed  of  two 
plates,  "to  compensate  by  its  tliickness  for  the  deficiency  of 
the  alveolar  ridge."  The  drum  is  seen-  rising  from  the 
palate  plate,  to  which  it  is  soldered. 

In  Fig.  270  is  represented  a  lateral  view  of  the  piece. 
The  palate  plate  and  drum  are  composed  of  fine  gold,  and 
made  very  light. 

At  the  time  Mr.  Rowell  constructed  this  obturator,  we 
are  assured,  by  Dr.  Griscom,  he  had  never  heard  of  nor  seen 
"Delabarre's  proposed  operation,"  so  that  it  would  seem  that 
the  obturator  which  he  constructed  was  original  with  him- 
self.    We  are  also  informed  that  it  has  been  worn  since 


880  ARTIFICIAL   PALATES   AND   OBTURATORS. 

1841,  and  as  yet,  (184*7,)  lias  not  caused  any  appreciable 
increase  in  the  size  of  the  opening.  That  this,  however, 
will  ultimately  be  the  case,  we  think  there  can  be  no  ques- 
tion. 

Dr.  Mutter  gives  an  engraving  of  an  artificial  palate, 
complicated  with  several  artificial  teeth  and  a  metallic 
velum  connected  with  the  palate  by  means  of  a  hinge,  con- 
structed by  Mr.  Neil,  a  dentist,  of  Philadelphia,  which  is 
represented  as  having  answered  an  excellent  purpose.*  It 
is  difficult  to  conceive,  however,  how  a  gold  plate  of  an  oval 
shape,  could  be  made  to  perform  the  functions  of  the  velum 
palati.  So  far  as  an  imperfection  in  the  hard  palate  is  con- 
cerned, the  evil,  we  know,  may  be  remedied  by  covering  the 
opening  with  a  metallic  plate,  but  the  loss  of  the  soft  palate 
cannot  be  replaced  with  any  hard  unyielding  material,  so 
as  to  restore  the  functions  of  the  natural  parts. 

The  most  complicated,  and  at  the  same  time,  ingenious 
piece  of  mechanism^  of  which  we  have  ever  heard,  for  re- 
placing the  loss  of  the  entire  palate,  including  the  velum 
and  nearly  all  the  teeth  of  the  upper  jaw,  was  invented  by 
M.  Delabarre,  but  in  consequence  of  its  weight,  from  the 
amount  of  material  in  it,  as  well  as  the  complexity  of  the 
instrument,  it  failed  to  realize  the  sanguine  expectations  of 
the  inventor^  although  he  states  that  it  fully  answered  the 
purpose  for  which  it  was  designed.  Subsequent  experi- 
ments, however,  have  been  less  successful,  and  as  this 
method  of  constructing  artificial  palates  has  long  since  been 
abandoned,  we  do  not  think  it  necessary  to  quote  the  de- 
scription which  he  has  given  of  it. 

Instead,  therefore,  of  employing  this  complicated  instru- 
ment, a  simple  palate  plate,  raised  upon  its  upper  surface, 
with  a  velum  like  the  one  constructed  by  Mr.  Stearns,  or 

*  Vide  Jjiston's  and  Mutter's  Surgery, 


ARTIFICIAL   PALATES  AND    OBTURATORS.  881 

with  Hullilien's  or  Blandy's  valve^  with  artificial  teeth  at- 
tached to  it,  will  be  found  to  answer  a  much  better  purpose, 
in  a  case  like  the  one  for  which  M.  Delabarre's  complicated 
piece  of  mechanism  was  fabricated.  As  it  is  not  probable 
that  such  an  appliance  will  ever  be  constructed  again,  we 
do  not  deem  it  necessary  even  to  copy  the  engraving  fur- 
nished by  the  author. 

M.  Desirabode  proposes  a  kind  of  platina  obturator  for 
congenital  fissure  of  the  palate,  by  which  he  thinks  the 
sides  of  the  alveolar  border  may  be  so  approximated  as  to 
favor  the  union  of  the  divided  parts.  It  consists  of  a  pla- 
tina plate  fitted  to  the  vault  of  the  palate  and  fastened  to 
the  teeth  by  means  of  three  crotchets,  (clasps,)  soldered  to 
each  side,  so  as  to  cap  the  canine  teeth,  the  bicuspid,  and 
two  of  the  molar  teeth,  bent  upon  the  alveolar  border,  in 
such  a  manner  as  to  maintain  the  whole  pressure.  After 
the  plate,  with  these  appendages,  has  been  well  adapted,  it 
is  divided  from  before  backwards  along  the  median  line,  and 
then  a  piece  is  removed  from  each  side,  so  that  the  two  edges 
may  be  separated  about  half  an  inch  from  each  other.  The 
two  half  plates  are  now  united  by  means  of  a  thick  and  re- 
sisting band  of  caoutchouc,  made  fast  by  riveting.  The 
plates  thus  united,  form  a  smaller  obturator  than  the  plate 
before  it  was  divided,  so  that  it  can  only  be  applied  by  put- 
ting tlie  caoutchouc  upon  the  stretch,  which  is  effected  by 
means  of  two  stocks^  so  contrived  as  to  force  the  two  plates 
asunder.  After  the  plate  is  properly  adjusted,  these  are 
removed,  when,  by  the  contraction  of  the  caoutchouc,  the 
sides  of  the  alveolar  border  are  gradually  made  to  approach 
each  other. 

It  sometimes  happens  that  an  imperfection  of  the  palate 
is  accompanied  by  an  opening  into  the  maxillary  sinus.  In 
this  case,  the  palatine  plate  should  be  large  enough  to  close 
both  openings,  and  the  loss  of  the  alveolar  border  replaced 
by  means  of  a  raised  plate,  soldered  to  the  lower  surface  of 
the  palate  plate^  and  to  which  artificial  teeth  may  be  at- 
tached. 


DENTAL  SURGERY 

882  ARTIFICIAL   PALATES     AND   OBTUEATORS. 

In  conclusion,  it  only  remains  to  observe  that  the  same 
attention  is  required  to  prevent  injury  to  the  natural  teeth, 
which  serve  as  a  support  to  an  artificial  palate  or  obturator 
as  to  those  which  are  used  for  the  retention  of  dental  sub- 
stitutes, and  as  full  directions  have  already  been  given  upon 
this  subject,  it  is  not  necessary  to  repeat  them  here. 


LIBRARY 

BALTIMOPe  COLLEGE  OP 

DENTAL  SURGERY 


i:^;ri3EX. 


Abrasion  of  the  teeth,  spontaneous, 
Mechanical,       .... 
Abyssinian  negroes,  customs  among, 

concerning  the  teeth  of, 
Accretion  of  the  jaws. 
Acids  of  the  mouth. 
Alveolar  abscess,     .... 
Cases  of,        .        .        .  531, 

Causes  of,  ...     142, 

Treatment  of,       . 
Arches,  shape  of  in  infants  and 

adults,    .         .         ■         • 
Processes   and   gums,  eflfects  of 

mercury  on. 
Treatment  of,    . 
Exfoliation  of,  in  children, 
Causes  of,  ... 

Sj-mptoms  of,         .         .         . 
Treatment  of,     . 
Necrosis  and  exfoliation  of  the, 
Cases  of,     . 
Causes  of,       . 
Treatment  of,     . 
Gradual  destruction  of  the, 
Causes  of,  ... 

Treatment  of,         .         .         . 
Tumors  of  the,  and  gums,     . 
Causes  of,       . 
Treatment  of. 

Amalgam, 

Anaesthetic  agents  in  the  extraction 
of  teeth, 
Amylene,  .... 

Chloroform, 

Congelation,     .         .         .         • 
Ether,  .... 

Electro-galvanism, 
Anatomy    and     physiology    of   the 

mouth,        .... 
Anajmia,  color  of  gums  in. 
Antagonizing  model,  how  to  obtain 

an, 

For  block  teeth. 
Instrument  for,  Dr.  Evans', 
Antrum  Ilighinorianum,         .        34, 
Abscess  of. 

Cases  of,        ...        • 
Causes  of,  ... 

Symptoms  of,         .         .         . 
Treatment  of, 
Boundaries  of  the,    . 


446 
450 


281 
148 
272 
530 
533 
532 
532 

144 

515 
516 
517 
519 
518 
520 
538 
540 
542 
542 
543 
544 
545 
522 
522 
524 
294 

410 
416 
414 
416 
414 
418 

27 
232 

732 

702 
736 
551 
589 
595 
593 
592 
593 
34 


Antrum  Highmorianum — 
Caries  of  the  walls  of, 

Cases  of, 

Causes, 

Symptoms  of. 

Treatment  of,     . 
Causes  of  diseases  of  the, 


Page. 

555,  608 
613 

.,  610 
609 
611 

,     556 


Exostosis  of  the  bony  walls  of  the,  637 

Cases  of,  ...  645 

Causes  of,       .         ...     641 

Symptoms  of,    .         .         .  640 

Treatment  of,        .         .        .     641 

Foreign  bodies  in  the,  .        651 

Symptoms  of,         .         .        .     652 

Treatment  of,     .         .        .        653 

Inflammation  of  the,  .     554,  559 

Causes  of,  ...        562 

Symptoms  of,         .         .         .     560 

Treatment  of,     .         .         .         562 

Insidious  occurrence  of  disease  in,  551 

Morbid  affections  of,  similar  to 

those  of  the  nose,  .        554 

Mucous  engorgement  of  the,    .     555 
Penetrated  by  teeth,     .         .        557 
Purulent  secretions  and  engorge- 
ment of  the,    .         .         555,  564 
Cases  of,        ...         .     577 
Causes  of,  ...        570 

Symptoms  of,        .         .         .     568 
Treatment  of,     .         .        .        671 
Secretions  of  the,  healthy,       .     566 
Tumors  of  lining  membrane  and 
periosteum  of  the,      .        .     617 
Cases  of,     .        .         .         .        625 
Causes  of,       .        .        .         .     622 
Symptoms  of,     .         .         .        621 
Treatment  of,         .         .         .     622 
Ulceration  of  lining  membrane 

of  the,  .  .  .  .699 
Cases  of,  ....  605 
Causes  of,  ...  •  601 
Symptoms  of,  .         .  600 

Treatment  of,        .        .        .    602 
Variable  character  of  the  mor- 
bid growths  of,  .         .     619 
^  When  discovered,          .         .        551 
By  whom,      ....     551 
Why  so  called,       .         .        .        661 
Wounds  of  the  osseous  parietes 
of  the,    ....        647 
Case  of,          ....     648 
Treatment  of,     .         .        .        648 
Argillaceous  tooth  polisher,    .        .     276 
Arranging  porcelain  teeth  on  a  plate,  739 


884 


INDEX 


Page. 

Arsenic  for  destroying  dental  pulp,     355 

Manner  of  appl.ving  it,      .        .     357 

A  reined  V  for  odontalgia,     .  382 

Artificial  teeth,        .         .         .         ,658 

Atmospheric  pressure,  principle 

of  applying,  .  .  ,  072 
Attached  to  plate  with  clasps,  G70 
With  spiral  springs,  .  .  071 
Different  methods  of  applj'ing,  068 
On  natural  roots,  .  .  .  068 
Substances  employed  for,  .  662 
Surgical  treatment  preparatory 

to  the  application  of,      .         670 

With  gums  mounted  on  plates,     709 

Artificial  palates,         .        .         .  876 

Arteries, 88 

Facial,  ....  89 

Branches  of,  ...       90 

Lingual,         ....  93 

Of  deglutition,  ...       92 

Of  insalivation,      ...  92 

Of  mastication,  ...       90 

Of  pharynx,  ...  92 

Of  prehension,  ...       89 

Of  soft  palate,        ...  91 

Ranine, 93 

Artery,  external  carotid,     .         .  89 

Branches  of,  ...       93 

Inferior  dental,      ...  90 

Inferior  palatine,      ...       93 

Infra-orbitar,         ...  91 

Internal  carotid,       ...       89 

Course  of,  ...  89 

Internal  maxillary,  .         .       90 

Spheno  palatine,  .         .  91 

Superior  dental,        ...       91 

Temporal,      ....  91 

Astringent  lotion  for  the  mouth,        510 

Recipes  for,  .         .        .        510 

Bell's, 510 

Koecker's,  .        .        .        510 

Author's,       .        .        .        .511 
Atmospheric    pressure,    method    of 

applying  artificial  teeth,  072 
Necei^sity  of  perfect  adaptation  in, 672 
Preferable  when  it  can  be  em- 
ployed, .  .  .  .675 
Size  of  "plate  necessary  to,  .  775 
With  narrow  base,  and  Roper'a 
improvement,  .         .        677 

Atrophy  of  the  teeth,  .  .  .  421 
F'irst  variety,  ...  424 
Second  variety,  .  .  .  425 
Third  variety,  ...  426 
Case  of,  ....     430 

Causes  of,  ...        427 

Treatment  of,        .        .        .     431 


B. 


741 


Backing  porcelain  teeth. 

How  to  proceed  when  alveolar 

ridge  is  uneven,  .         .     644 

Bell,  researches  of  Mr.  T.,  .         Ill 

Berzelius' analysis  of  dentine,  .     '53 

Bicuspids,  manner  of  separating  the,  280 
Block  teeth,  objections  to,       .         .     779 
Material  used  in  making  porce- 
lain,        ....        779 


Paoe. 
Block  teeth — 

Materials  used  in  making  color- 
ing for,       ....     781 
For  body  of,       .         .         .        786 
For  enamel,  .         .        .     787 

Blood,  importance  of  pure,  .         210 

Of  children,  serous,  .         .     244 

Blow-pipe,  ....        730 

Elliott's  improved  self-acting,  726 
Parmly's  self-acting,  .        725 

Somerby's  compound,       .         .     628 
Borax,  how  prepared  for  soldering,    724 
Glass  of,  how  made,  .         .     790 

Brahmins,   customs   concerning   the 

teeth  of,  ....         282 

Brush,  polishing,     ....     740 
Buccal  roots,         ....  64 

Building  on  the  whole  or  part  of  the 

crown  of  a  tooth,       .         .     367 
Preparation  of  gold  best  adapted 

for, 369 

C. 

Caries  of  the  teeth,  .         .        .     256 

Bew's  theory  of,  .        .        269 

Chemical  theory  of,  .         .     272 

Causes  of,       ...         .        265 
Differences  in  liability  of  differ- 
ent teeth  to  be  attacked  bv  it,  259 
Fox  and  Bell's  theory  of,       261,  262 
Indirect  causes  of,  ,         .        274 

Inflammation  of  the  dentine,  not 

a  cause  of,  ...     267 

Lintot's  theory,     .         .  271 

No    analogy    between     it    and 

caries  of  bone,  .  .  266 
Man  almost  the  only  animal  af- 
fected with,  .  .  .269 
Prevention  of,  .  .  .  275 
Secret  development  of,  .  .  256 
Seldom  occurs  amongst  Indians,  270 
Tome's  theory  of,  .        .         271 

Treatment  of,  .  .  .  276 
Vital  theory  of,  .  .  266,  267 
Where  first  developed,  .        256 

Carneous  tubercle,  .         .         .     141 

Functions  of,  ...         142 

Singular  development  of,         .     145 
Cartilaginous    excrescences    of    the 

gums,  .         .         .         .527 

Causes,  ....        528 

Casserian  ganglion,  ...       96 

Branches  of,  ...  96 

Cassius,  purple  powder  of,      .         .     783 

Recipes  for,  .        .         .         783 

Catalan,  inclined  plane  of,      .         .     160 

Cattle,  teeth  of,  ...         663 

Cavities  in  teeth,  filling  individual,     310 

Of  reserve,        ....     115 

Cavity  in  a  tooth,  instruments  for 

forming 295 

Manner  of  forming,       .        .        299 

Plates, 772 

Advantages  of,  .         .        772 

Disadvantages  of,  .         .     777 

Size  of,  for  a  single  tooth,         777 
With  valves,  .  .774 

When  invented,  .        .        773 


INDEX . 


885 


Page. 

Cementum, 57 

Chemical  constituents  of,      .  58 

Formation  of,  ...     128 

^'a8nlyt^l's  opinion  of  the,     .  57 

Structure  of  the,       ...       57 

Ceylonese  furnace,       .        .        .        694 

Characteristics  of  the  teeth,    ,         .     212 

Cheek  and  tongue  holder,    .         .        334 

Cheoplastic    method    of   mounting 

teeth,        ....       811 
Chloride  of  zinc  for  destroying  sen- 
sibility of  dentine,      .        .     460 
Clasps,  fitting  "and  attaching  to  plate,  720 
Fogle's  method  of  fitting,  .     721 

Cushman's  on,  .  .  .  722 
Noble's  method,  .  .  .  723 
Ought  not  to  be  applied  to  loose 

teeth,  ,         .         .         .759 

Teeth  not  to  be  filed  to  obtain 

space  for,        .         .        .        759 
Thickness  of  plate  for,      .         .     703 
Cleavcland's  air  chamber  plate,  772 

Coloring  materials  for  porcelain  teeth,781 
Consolidating  forceps,  .         ,        327 

Condyloid  process,  ...       37 

Constitution  influenced  by  regimen,   201 
Convulsions    of   infants    sometimes 

caused  by  teething,        .         136 
Copper,  how  to  remove  from  surface 

of  gold  plate,  .         .        745 

Corda  tympani,        ....       98 
Crowded  teeth,  how   to  correct  ar- 
rangement of,  .         .         156 
Practice  of  Delabarre  in,  .    156 
Bell  on,          ....         156 
Author's  experience  on,           .     156 
Crusta  petrosa,     ....  57 
Development  of,        .         .         .     128 
Structure  of,          ...          67 

D. 

Damp  residence,  eflfects  of  upon  the 

teeth,  .         ,         ,        .229 

D'Arcet's  metal,  ...        294 

Deafness,  sometimes  caused  by  en- 
largement of  the  tonsils,  80 
Decay  of  the  teeth,  causes  of,          .     265 

Character  of,  in  soft  teeth,  257 

Complicated,  .         .         .        258 

Differences  in  liability  of  diflfer- 

ent  teeth  to,        .         .         .259 

Duval's  classification  of,        .        258 

Hereditary  predisposition  to,        264 
Deformity   fiom   excessive  develop- 
ment of  the  teeth  and  alve- 
olar ridge,  .         .         .     175 

Authoi's  mode  of  treating,   '   .     175 
Deglutition,  organs  of,         .         .  75 

Arteries  of,       .         .         .         .92 
Delabarre,  metallic  grate  of,       .         171 

Fusible  enamel  of,     .         .         .     770 
Dental  groove,  primitive,  .        112 

Secondary,        ....     114 
Dental  pulp  and  periosteum,  diseases 

of, 456 

Dental  .substitutes,  for  special  cases,  751 

With  artificial  gums,  ♦^       .     769 


^  Page. 

Dental  ligament,  ...  87 

Dentes  sapientiae,  irregularity  of,       159 

How  caused,  .        .        .        159 

Dentine,  chemical  constituents  of,        53 

Nerve  filaments  of,        .        .  52 

Sensibility  of,  ...       52 

Structure  of,         ...  49 

Vascularity  of,  ...       52 

Dentist's  work  table  and  grinding 

lathe,  .        .        .         .740 

Dentition,  first,  ....  130 
Effects  sometimes  resulting  from, 134 
Irritation  of,  caused  by  pressure 

upon  the  pulp,  .  .  134 
Most  critical  periods  with  infants, 134 
Second,  ....        139 

An  important  period  of  life,  139 

Generally  overlooked  by  medical 

men,  ....     164 

Injury  done  to  by  improper  in- 
terference,        .        .        .     154 
Method  of  directing,      .         .         153 
Observations  of  Mr.  Bell  on,        153 
Wise  provision  in,        .         .        152 

Third, 190 

Supposed  origin  of,  ,  .  193 
Desirabode's  fusible  enamel  for  plates, 770 
Deviation  of  teeth,  singular  cases  of,  181 
Disease,  characteristics  of,  .         208 

Diseases  of  the  teeth,       .         .         .     257 
Diseases  and  defects  of  the  palatine 

organs,       ....     829 

Accidental  and  congenital,  829 

Of  the  palate,  .         .         .831 

Double  set  of  artificial  teeth,     .  662 

Draw  bench,  .         .        .         .699 

Drill  stocks,  ....        296 

Maynard's,        ....     297 

McDowell's,  .        .        .        297 

Lewis', 297 

Duhamel's  researches  on  the  teeth,    214 
Dunning,  Dr.  E.  P.,  on  filling  pulp 

cavities,  .         .         .        349 

Dwinelle's  cavity  plate,         .        .       773 
Dysmenorrhea,  appearance  of  gums 

in,  ....        233 

Dyspepsia,  effects  of  protracted,  upon 

the  gums,  .         .         .     248 

E. 

Elevator, 406 

Elliot's  forceps  for  removing  pivots,  683 
Empiricism  in  dentistry,  .        .     278 

Enamel, 54 

Chemical  constituents  of,  .     66 

Denudation  of,       .         .         .         221 

Formation  of,  ...     125 

Importance  of,       .        .         .        279 

Membrane,        ....     126 

Microscopic  appearance  of,  66 

Paste,  .  .  .787 

Structure  of,  .  .  66 

English  teeth,  how  attached  to  plate,  748 

Erosion  of  the  teeth,      .  .  422 

Excavators,  .  .  ,       296 

Excising  forceps,  .  .  679 

Exostosis  of  the  teeth,        .  .      435 


! 


^^^ 


886 


INDEX. 


Page. 

Extraction  of  teeth,  .  .       385 

Indications  for  the,  in  first  denti- 
tion, ...  387 
Of  second  dentition,  .  .  387 
Instruments  emploj'ed  in,  390 
Of  roots  of  teeth,  ,  405 
Instruments  for,  .  .  406 
Of  the  temporary,  .  411 
Hemorrhage  after,       .            .      411 

Eye  teeth,  ...  61 


Face,  bones  of  the,               .            .  40 

Fauces,  where  situated,            .  78 

File,  safe-sided,       .  .  .284 

How  held  in  using,             .  285 

Carrier,  Westcott^s,     .             .  287 

Files,  author's  patterns,           .  286 

Townsend's,      .            .            .  335 

Filing  the  teeth,            .            .  278 

Beneficial  in  certain  cases,      .  278 

Cleanliness  necessary  after,  283 

Does  not  necessarily  injure  the 

teeth,                .            .  282 
Judgment  required  in,            .  282 
Necessity  of,             .             .  282 
Remarks  on  by  Dr.  J.  Harris,  278 
Utility  of,                .            .  280 
When  improper,         ,            .  280 
Filling  teeth,     ...  288 
Individual  cavities  in,              .  310 
Inferior  incisors  and  cuspids,  328 
Molars  and  bicuspids,     .  330 
Lower  molars,  dilliculties  of,  333 
Materials  for,                .            .  290 
Over  exposed  pulp,            .  337 
Position  of  operator  whilst,  312 
Pulp-cavity  and  roots  of  teeth,  346 
Sensitive  teeth,            .            .  289 
Treatment  of,  preparatory  to,  289 
Special  airections  for,             .  299 
Superior  incisors  and  cuspids,  310 
Molars  and  bicuspids,           .  321 
When   lining   membrane  is  ex- 
posed,               .            .  337 
First    recommended    by    Dr. 
Koecker,                .            .  337 
With  crystallineor  sponge  gold,  360 
Floss-silk  for  cleaning  the  teeth,  275 
Fogle's  method  of  fitting  clasps,  721 
Forceps,  for  extraction  of  teeth,  392 
Dens  sapientiie,            ,            .  398 
Dentist's  punch,           .            .  741 
Hawk's-bill,            .            .  398 
Lower  molar,               .            .  395 
Incisor,    .             .             .     396,397 
Bicuspid,       .             .             .397 
Manner  of  using,                  .  401 
Superior  to  key,          .            .  393 
Snell's,         ...  394 
Improvement  of,  by  author,  394 
Upper  molar,                .            .  396 
Incisor  and  cuspids,        .  396 
Foster,  J.  II.  method  of  filling  pulp- 
cavities,     .            .            .  347 
Fractures  of  the  teeth,             .  452 
Frajnum,      ....  84 


Frsenum  linguffi, 

Fungous  growth  of  dental  pulp, 

Furnace  and  blow-pipe, 

G. 


PaG8. 

84 
476 
729 


Ganglion  of  Meckel,  .  .        97 

Gangrene,  dental,  .  .  257 

Gauge  plate,  .  .  .      702 

Genial  processes,  .  .  37 

Gilbert's  cavity  plate,        .  .       776 

Glands,  mucous,  .  .  73 

OfSerres,  .  .  .492 

Parotid,       ...  71 

Salivary,  .  .        71,  72,  73 

Sublingual,  .  .  73 

Submaxillary,  .  .        72 

Tonsil,  ...  80 

Gold,  alloying  of,  .  .       696 

Copper,  preferable  for,      .  696 

Crystalline  or  sponge  for  filling 

teeth,  .  .  .360 

Bar  of  Fox,  .  .  172 

Injurious  effects  of  impure,  697 

Fillings,  manner  of  finishing,       305 
Instruments  for  introducing,     303 
Manner  of  introducing,       .       305 
Foil,  ...  290 

Spongy  and  crystalline,  .       292 

Manner  of  refining  and  alloying,  690 
Plate,  manner  of  making,  701 

Refining,  .  .  .692 

Elliot's  method  of,  .  695 

Solder,  how  made,       .  .       703 

Recipes  for,  .  .  704 

Gomphosis,  .  .  .65 

Good,  Dr.,  on  dentition,  .  135 

Goodsir,  researches  of,      .  .       112 

Great  Britain,  peasantry  of,   noted 
for  good  teeth  and  constitu- 
tions, .  .  210 
Grinding  apparatus,           .            .       682 
Pratt's,     ...            682 
Lathe,   .           .            .           .740 
Gums,  the,          ...  85 
Acute  inflammation  of,            .      602 
Appearance  of  in  infants,  in  per- 
fect constitutions,             .       225 
Composition  of  Dr.  Allen's  con- 
tinuous artificial,              .      808 
Single  porcelain  teeth  with  con- 
tinuous,     .            .            .       805 
Atrophy  of,             .            .            226 
Indicative    of  premature  old 
age,             .            .            .226 
Color  of,  in  chlorosis  and  ana3mia,232 
Constitutional   health  indicated 

by,  ...       223 

Diseases  of,  .  .  500 

Predisposing  causes  of,        .       500 
Formulas  of  Dr.  Hunter  for  con- 
tinuous artificial,  .       806 
Effects  of  mercury  on,       .  263 
Indications  furnished  by,  of  mer- 
curial action,                .  232 
Inflammation  and  tumefaction  of,  503 
Causes  of,           .           .  503 


^: 


INDEX 


88*7 


Page. 

Gums — 

Treatment  of,      .  .  508 

Irritation  of,  proximate  cause  of 


disease  in. 
Insensibility  and  hardness  of, 
Internal  structure  of. 
Lancing  of,       . 

False  opinions  concerning. 
Morbid  growth  of. 
Causes  of,      . 
Treatment  of. 
Mercurial  inflammation  of. 

Treatment  of, 
Not  alwaysindicative  of  the  state 

of  health. 
Physical  characteristics  of 
Subject  to  general  laws  of  econ- 
omy,    . 
Thickness  of. 
Tumors  of, 

Ulceration  of,  in  children. 
Causes  of. 
Treatment  of, 
Gunnell's,  Dr.,  treatment  of  protru- 
sion oflower  jaw. 
Gustatory  nerve,  branches  of, 


223 

85 
85 
137 
138 
513 
614 
514 
515 
516 

224 
223 

223 
86 
522 
517 
519 
520 

179 
101 


40 


Head,  bones  of  the. 

Hemorrhage    after    extraction    of 

teeth,                .             .  411 

Cases  of,        .            .            .  412 

Bill's  stopping,              .            .  342 

Remarks  on,     .            .            .  342 

Hook,      ....  406 

Hullihen's  screw  forceps,               .  409 

Human  teeth,     .            .            .  662 

Hunter,  Dr.  John,  researches  of,  110 
Hunter's,  Dr.  Wm.  M.,  continuous 

artificial  gums,             .  806 

I. 

Impression  in  wax,             .            .  705 

Plaster  of  paris,      .            .  709 
Desirabode's  method  of  obtaining,710 

Inclined  plane  of  Catalan,              .  170 

Improved  by  author,          .  171 

Incorruptible  teeth,            .            .  666 

Inferior  maxillary  bone,           .  35 

Divisions  of,     .            .            .  36 

Alveolar  processes  of,        .  37 

Anterior  mental  foramen  of,  36 

Articulations  of,     .            .  38 

Condyloid  processes  of,           .  37 

Coronoid  processes  of,        .  37 

Development  of,           .            .  37 

Genial  processes  of,            .  36 

Posterior  dental  foramina  of,  37 
Rami  of,            ,            .            .37 

Structure  of,           .            .  37 

Ingot  mould,           .            .            .  701 

Injury    resulting    from    neglect    of 

teeth,                .            .  154 

Insalivation,  organs  of,        .            .  71 

Arteries  of,          .            .  92 

Intemperance,  efi'ects  of,          .  226 


Page. 

Introducing  and  consolidating  crys- 
talline gold,  .  .       365 
Irregularity  of  the  teeth,          .  159 
Aid  of  dentist  required  in,  162 
Cases  of,       .            .            .  166 
Catalan's  inclined  plane  in  cor- 
recting,     .            .            .       170 
Causes  of  failure  in  correcting 

in  advanced  life,  .  162 

Caused  by  want  of  room,        .       163 
Contraction   of  upper  jaw,  fre- 
quent cause  of,  .  163 
Defect  in  conformation,  a  cause 

of,  ...      161 

Directions  of  Fox  in,  .  162 

File  never  to  be  used  in,  156 

Gum  elastic  in  correcting,  168 

Importance  of  earl}'  attention  to,  162 

Ligatures  in  correcting,  .       165 

Of  bicuspids,  .  .  160 

Ofcuspidati,     .  .  .       164 

Of  dens  sapientise,  .  160 

Of  incisors  of  upper  jaw,        .       164 

Of  molars,  .  .  160 

A  predisposing  cause  of  disease,  158 

Spiral  springs  in  correcting,        168 

Treatment  of,  .  .       162 

Where  the  under  teeth   shut 

outside  of  the  upper,  169 

Fox's  plan  of  correcting,        .       172 

Most  suitable  age  to  correct,        173 

Itinera  dentium,  .  .  117 

Ivory  for  artificial  teeth,  .      664 


Jaw,  partial  luxation  oflower,  178 
Protrusion  of  lower,    .  .       178 
Treatment  of,      .             .  178 
Time  required  for,  .       179 
Superior,  excision  of,         .  579 
Jaws,  accretion  of  the,       .  .       148 
Change  of  countenance  produc- 
ed by,               .            .  160 
When  commenced,      .  .       148 
Defects  of                .            .  151 
Regarded  as  hereditary,  161 

K. 

Key  of  Garengeot,              .  .      390 
Manner  of  using,     .            .  399 
Koecker,  remarks  of,  on  second  den- 
tition,              .            .  158 


Lateral  cavity  plates,  .  773 

Lavater,       .  .  •  .205 

Lead,  in  covering  exposed  lining 

membrane,  .  •       340 

Pattern,      ...  719 

Leeches  to  the  gums,  when  necessary,467 
Ligamentum  dentis,      .  .  87 

Lips,  characteristics  of  the,  .       243 

Sign  of  a  good  or  bad  constitu- 
tion, .  .  .       243 
Lithodeon,            ....        294 


^W 


^f*^ 


INDEX 


Page. 

Lower  jaw,  dislocation  of,      .        .    481 

Reduction  of,         ...        483 

Method  of  Sir  Astley  Cooper 

fortbe,  .        -        .        484 

M. 

Malar  process,         ....  34 

Mastication,  active  organs  of,     .  67 

Arteries  of,       ....  90 

Inferior  dental,           .        .  90 

Infia-orbitar,         ...  91 

Internal  maxillary,             .  90 

Spheno-palatine,            .        .  91 

Superior  palatine,      .        .  91 

Superior  dental,    ...  91 

Temporal,           ...  91 
Muscles  of,     .         .        .         .67 

Massetor,             ...  68 

Pterygoidens  externus,          .  69 

rterygoideus  internus,      .  70 

Temporalis,            ...  68 

Passive  organs  of,      .         .  31 

Inferior  maxilla,            .         .  36 

Palate  bones,      ...  39 

Superior  maxilla,          .         .  31 
Materials  used  for  porcelain  block 

teeth,  .         .         .         ,779 

Matrix  for  moulding  block  teeth,  793 

Maxillary  sinus,       ....  551 

Maynard's  forceps,       .         .         .  410 

Mechanical  abrasion  of  teeth,          .  450 

Provision  of  nature  to  prevent 

exposure  of  pulp,        .        .  450 

Mechanical  dentistrj-,           .         .  655 

Violence,  injuries  from,     .         .  452 

Case  of,  by  author,     .        .  554 

Mental  process,        ....  37 

Metallic  pivots,     ....  684 

Model  and  counter-model,       .        .  714 

Manner  of  procuring,             .  714 

Without  sand,       .         .         .  714 

Mineral  cement,            .        .        .  294 

Models  of  the  mouth,      .        .         .  711 

Desiiabode's  method  of  making,  710 

Molar  teeth,  with  five  roots,        .  182 

Mother,  health  of,  indicated  by  teeth 

of  child,      .  .  .203 

Difficulty  of  such  diagnosis,  205 

Moulding  and  carving  block  teeth,  796 

Mouth,  acid  in  the,             .            .  273 

Anatom}-  and  physiology  of,  27 

Anatomical  relations  of,          .  104 

Arteries  of,              .            .  88 

External  carotid,      .            .  89 

Internal  carotid,             .  89 

Blood  vessels  of,           .             .  88 

Boundaries  of,         .            .  27 

Elements  of,      .             .             .  27 

Fluids  of  the,  characteristics  of,  240 


Mucous  membrane  of, 

Muscles  of  the, 

Origin  and  insertion  of  the, 

Nerves  of,  . 

Physiological  relations  of. 

Surgical  treatment,  prepara- 
tory to  application  of  arti- 
ficial teeth, 


84 
28 
29 
95 
105 


676 


Paob. 

Mouth — 

Veins  of,           .            .  .        94 

"Wash,           ...  510 

Recipe  for,  author's,  .       611 

Mucous  glands,               .            .  73 

Use  of  the,        .            .  .74 

Membrane,  when  called  gums,  85 

Muscles  ol  the  mouth,        .  .        28 

Buccinator,             .            .  30 

Depressor  labii  inferioris,  .        29 

Depressor  labii  superioris,  30 

Depressor  anguli  oris,  .        29 
Levator  labii  superioris  alaque 

nasi,            .            .  .29 

Levator  anguli  oris,            .  29 

Levator  labii  inferioris,  .         30 

Orbicularis  oris,      .  30 

Zj-gomaticus  major,  .         29 

Zygomaticus  minor,  29 

N. 


Nasmyth,     Microscopical    observ 

tions  of, 
Nasal  crest, 

Spine,  . 

Natural  teeth,  mounting. 
Necrosis  of  alveoli. 
Causes  of, 
Treatment  of. 
Case  of,  by  Dr.  Maynard, 
Nerves  of  the  mouth,    . 

Fifth  pair. 
Nerve,  anterior  dental. 
Anterior  auricular. 
Cervical, 
Digastric, 
Facial, 
Branches  of. 
Nerves,  facial,  superior. 
Inferior,     . 
Branches  of. 
Origin  of. 
Frontal, 
Gustatory, 
Infra  orbitar. 
Inferior  dental,  . 

Maxillary, 
Branches  of, 
Lachrymal, 
Lateral  nasal. 
Maxillary, 
Nasal, 
Opthalmic, 

Branches  of. 
Orbital, 
Palatine, 
Posterior  dental. 
Posterior  auricular,     . 
Stylo-hyoid, 
Submaxillary, 
Superior  maxillary, 

Branches  of,  . 

Of  tooth,  modes  of  destroying. 

Author's  method, 
Maynard's  method, 
Gutta  percha,  in  exposed. 
Filling  over  exposed. 


44,48 

36 

33 

748 

538 

542 

542 

541 

95 

96 

101 

100 

104 

103 

103 

103 

103 

103 

103 

102 

96 

101 

99 

101 

100 

100 

97 

98 

103 

97 

96 

96 

99 

98 

99 

103 

103 

104 

97 

97 

356 

357 

357 

344 

337 


INDEX 


889 


Nerves  of  t.ioth.  fillinj;  over  oiposed — 


Hullihen's  method, 

.     344 

Vidian  or  pteryjjoid, 

98 

Nitrate  of  silver  lotion,    . 

.     511 

0. 

Obtui-ators.  aitificial, 

.    8G4 

Fiist  description  of, 

8G4 

Manner  of  constructing, 

.     805 

Oral  teeth,      .... 

61 

Os-hyoides, 

.       83 

Osteo-sarcoiuatous  tumors. 

5-28 

Osseous  union  of  teeth. 

.     186 

Cases  of,          .... 

186 

Causes  of,           ... 

.     187 

Kare  occurrence  of. 

187 

Ox\d  of  cobalt, 

.     785 

Of  g;old,  mode  of  preparing, 

782 

Oxyd  of  manganese, 

.     785 

"  Of  silver,         .... 

685 

Of  titanium. 

.     785 

Of  uranium, 

785 

831 

837 

840 

839 

839 

77 

831 

835 

833 

834 

802 

39 

40 

39 

40 

40 

40 

40 


I'alate,  diseases  of  tlie, 

Caries  and  necrosij  of  bones  of. 
Cases  of,      .... 
Causes  of,        .... 
Treatment  of. 
Muscles  of  the. 
Tumors  of  the. 

Cases  of,  .... 

Causes  of, 
Treatment  of, 
Palates,  artificial. 
Palate  bones,     ..... 
Articulation  of, 
Divisions  of,       .         .         .         • 
Nasal  palate  of. 
Orbital  processes  of, 
Uelations  of, 
Structure  of,      • 
Imperfections  of  the,  with  open 
ing  into  maxillary  sinus. 
Palate  plate,  simple  or  obturator, 

With  drum  on  convex  surface  868 
Artificial,    with    velum    and 
uvula,      .         .        .        • 
Dr.  Tucker's  instrument, 
Dr.  Hullihen's  instrument. 
Dr.  Blandy's  instrument, 
Mr.  Steam's  instrument, 
Complicated    with    artificial 
teeth,  .... 

Palatine  obturator  of  M.  Desirabode 

for  closing  congenital  fissure,881 

Palatine  organs,  defects  of,  ■        827 

Accidental,     ....     829 

Congenital,  ...         829 

Functional  disturbances  caused 

by,  ....        851 

Manner  of  remedying  defects  of,  855 

Paste,  terra-metallic,  .        .        770 

Parotid  glands,         ....       71 

Structure  of,  ...  72 

Parotidean  plexus,  .        .        .    103 


881 
867 


869 
871 
873 

875 
871 

870 


Pat.k. 

Parraly's  self-acting  blow-jiipe,  725 

Perio.steuni,  alve(ilo-di-ntal,  ■  86 

Inflammation  of,        .         •         •     473 

Pes  anserinus,        •         .         .         ■         103 

Pharynx,  the,  •         .         .         .       75 

Arteries  of,     ...        .  92 

Muscles  of,  .        •        ■         •      7G 

Physiognomical  semiotics,  important 

to  the  physician,  .  •  206 
Pickling  after  soldering,  .  •  7t5 
Plaster  of  paris,  impressions  of  the 

mouth  in,         •         •         •         709 
Composition  of,  ■         •         •     709 

Model,  manner  of  m;iklng  a  sec- 
tional, .  .  •  -713 
Plate,  fitting  and  swaging,  .  719 
How  to  el'.'an  after  soldering,  745 
Manner  of  finishing  and  applying  745 
Width   of.    required   for    upper 

sets  of  teeth  with  springs,       762 

Platina  sponge,  how  prepared,        .     783 

Plethora,  signs  of,         •         •         ■         245 

Porcelain  teeth,        ...  666 

Single,  on  metallic  base,       759,  805 

Block  teeth,  •        .        .779 

Appearance  of,  when  mounted,  803 

Crucing  or  biscuiting,        .        797 

Double  sets  of,       .         .         -803 

Enameling  of,     .         .         .         798 

Fitting  and  attaching  to  plate,  801 

Materia's  for,  •         •         .     778 

Moulding  and  carving,       .         796 

Platina,  pins  of,     .         •         .798 

Superiorit}'  of,  .        .        779 

Posterior  nasal  spine,       ...       39 

Posterior  palatine  canal,      .         .  39 

Palatine  foramen,      ...       39 

Pratt's  lathe,         ....         682 

Prehension,  organs  of,     .        •        .       28 

Prevention  of  caries,     •         .         •         275 

Protrnsi(m  of  lower  jaw,  •        .     178 

Providence,  wisdom  of,  displayed  in 

dentition,  •         .        .     130 

Pulp,  dental,  ....  43 

Converted  into  ostco-dentine,  33!) 
Fungous  growth  of,  .        .     476 

Microscopical  appearance  of,  43 

Nerves  of,  ....      45 

Ossification  of,  .  .  .  477 
Size  of  vesicles  of,  .  .  .  43 
Spontaneous  disorganization  of,  475 
Vessels  of,  ....       44 

Pulp-cavity,  manner  of  proceeding 
when  caries  has  nearly'  reached 

the, .307 

Punch,  tooth,        ....        406 

U. 


Ramus 

)f  lower  jaw. 

37 

Raschkow,  researches  of. 

125 

Red  gum. 

.     136 

Refining  gold, 

692 

Elliot's  method, 

.     695 

Retzius 

researches  of. 

50 

Rickets, 

supposed  to   be 

caused 

bv 

dentition, 

152 

Rolling 

mill, 

701 

0/ 


890 


INDEX 


Paoe.  I 

Roots  of  teeth,  effort  of  nature  to         \ 

expel,        .         ;         .        .         259 

Manner  of  extracting,       .        .     405 

Rouge,  jeweler's,  how  made,       ■        740 

S. 

Saliya,  acquires  new  properties  by- 
being  kept  in  the  mouth,        242 
Scarce  when  health  is  good,         242 
Appearance  in    good    constitu- 
tions,       ....        240 
Salivation,  favorable  sign  in  conflu- 
ent small  pox,  .        .        240 
Salivary  glands,       •        ...       71 
Parotid,           ....  71 
Sublingual,        •        ...      73 
Submaxillary,        ...  72 
Calculus,            .        .         .        .489 
Characteristics  of,      .        .        234 
Formation  of,         .         .         .     491 
Effects  of,  upon  the  teeth,          496 
Manner  of  removing,           .         497 
Sanguineous  temperaments,  kind  of 

gums  in,  ...        228 

Screw,  conical,         ....    407 
Schwerdt's  needle-holder,  .        860 

Scorbutic  tendencies,  gums  in,        •     231 
Scrofulous  persons,  gums  of,        •        231 

Scurvy, 500 

Self-acting  blow-pipe,  .        •        725 

Elliot's  improvement  of,  .     726 

Sensibility  of  the  teeth,  how  to  de- 
stroy, ....     290 
Septic  acid  formed  in  the  mouth,        272 
Separation  of  the  teeth  by  pressure,  301 
Gum  elastic  for,        .        .        .     301 
Soft  palate,  the,  ...  77 
Arteries  of,        .        .        .        .       92 
Solder,  manner  of  making,          .        703 
Recipes  for,        ....     704 
How  to  prevent  from  running  in 

wrong  direction,        .        .     731 

Soldering, 724 

Lamp,         .        .        -        .        .     730 

Somerby'^  furnace,       •        •        .        728 

Spheno-palatine  ganglion,       .        .      98 

Spheno-palatine  foramen,      .         .        39 

Spina  ventosa,  ....     439 

Causes  of,      .         .         .         .        440 

Treatment  of,  ...     440 

Spiral  springs,  manner  of  making,      699 

Machine  for,  .        .         .     700 

Spongy   growth   of  the  gums,   of 

what  indicative,         .        .     231 

Spontaneous  ulceration  of  the  gums,  517 

Springs,  spiral  attachments  for,  763 

Length  of,  ...         764 

Springing  of  plate,  how  caused,         766 

Staphyloplasty,  .         .         .         787 

Staphyloraphy,        ....     856 

Directions  for  operations  of,         857 

Instruments  necessary  for,       .     857 

Operation  of,  first  conceived  by 

LeMonnier,        .        .         .     856 
Performed  upon  a  child,       .        856 
M.  Roux,  method  of  knotting 
ligature,  .        .        .        859 


Paoe. 
Steno,  duct  of,  ....  72 
Strumous    dispositions,   gums   met 

with  in,  ...         228 

More  common  to  females  than 
males,     ....         228 

Stub's  files, 287 

Submaxillary  glands,  .         .  72 

Sublingual  glands,  ...       73 

Substitutes,  dental,  for  special  cases,  751 

For  upper  bicuspids,  with  clasps,  754 

Roper's  plan,         .        .         .     755 

For  central    incisor  with   one 

clasp,  ....     751 

With  two  clasps,        .         .        752 
For  incisors  and  cuspidati,  753 

For  incisors,  cuspidati   and  bi- 
cuspids with  clasp,  .        755 
For  lateral  incisors  and  left  bi- 
cuspids, with  two  clasps  on 
one  side,          .        .         .        756 
For  two   central  incisors,  with 

clasps,    ....        753 
For  two  bicuspids,  with   clasp,     764 
Suction  method  of  applying  artificial 

teeth,  ....     765 

Superior  maxillary,  removal  of,  691 

Mr.  Liston's  method  of,         .        C93 

Alveolar  processes  of,       .        .       32 

Anterior  dental  canal  of,         .        33 

Articulations  of,  .         .  34 

Infra-orbitar  canal,  .        .     33 

Structure  of,  ...  34 

Symphysis  of  lower  jaw,         .         .       36 

Sympatheticus  minor,  .         .        104 


T. 


Tartar,  .... 

All  persons  subject  to  it, 
Chemical  constituents  of. 
Color  of,  .... 

Composition  of,     . 
Dark  blown,     .        .         .         . 

Effects  of,  ... 

Indications  of,        .        .        . 
Daik  green. 

Children  subject  to  it. 
Density  of,  variable,  . 
Drv  black,        .        .        .        . 

Effects  upon  the  gums. 

Second  variety,     . 

Effects  of,        .         .         . 
Dry  yellow  or  light  brown, 

Kfiects  in  scorbutic  subjects, 
Its  diagnostic  import, 

Not  alone  to  be  relied  upon, 
Pale  or  yellow  brown. 

Where  found. 

Effects  of,            ... 
White, 

Under  what    circumstances, 
found,         .         .        .         . 
Composition  of,     . 
Effects  of,  .        .        .        • 

Teeth,  the,  .... 

Abrasion  of,  spontaneous, 
Mechanical, 
Articulation  of,        .        .        . 


234,  489 
.  234 


490 
234 
235 
236 
237 
237 
238 
238 
235 
235 
235 
235 
236 
234 
223 
234 
234 
237 
237 
237 
237 

237 
237 
237 

39 
446 
450 

65 


INDEX 


891 


Paoe. 
Teeth- 
Atrophy  of,  ...        421 
Bicuspid,           .         .         . '       .       61 
Why  so  called,  .         .  61 
Bell's,  Mr.,  observations  upon,       65 
Buccal,          ....          64 
Calcareous  salts,  of,  whence  de- 
rived,         .         .         .        .214 
Caries  of,       ....         256 
Seldom  occurs  after  forty,        263 
Characteristics  of,          .         .         212 
Classes  of,          ....     212 
First,           ....         212 
Where  found,     .         .              212 
Opinion    of    Lavater    with 
regard,         ...         208 

Second, 215 

Indicative  of  a  weak  consti- 

tion,  .         .         .         .216 

Generally    found    among    fe- 
males ...         216 
Most  prevalent  in  the  United 
States,  ...        216 
Third,             .         .         .        .217 
Fourth,       ....         218 

Fifth 219 

Crowded,  how  to  correct,  156 

Cuspidati,  .  .  61 

Cuspidati,  functions  of,  .       61 

Deformity  caused  by   excessive 

development  of,  .  175 

Treatment  of,  .  .       175 

Density  of,  increased  by  age,        200 

Denuding  of,  .  .       442 

Causes  of,  .  .  443 

Treatment  of,  .  .       445 

Description     of,    belonging    to 

each  class,  .  .         59 

Differences  in  liability  of  differ- 
ent, to  decay,  .  259 
Diseases  of  the,            .            .       255 
Not  analogous  to  those  of  bone,  255 
Displacement  of,     .             ,  547 
Causes  of,      .             .             .       548 
Treatment  of,      .            .            548 
Early  development  of,  but  little 
known  to  the  ancients,            109 
First  noticed  by  Kustachius,      109 
Exostosis  of  roots  of,                .       435 
Case  of  by  Dr.  .Swa/.ey,             436 
Case  of  bV  Mr.  Fox,             .       436 
Case  of  by  author,          .            436 
Causes  of,      .            .            .       437 
Treatment  of,       .             .             438 
Extraction  of,               .            .       385 
Consequences  of  carelessness  in,3S5 
Indications  for,                .            387 
Instruments  emploved  in,          390 
Eye,      .             .          ".            .61 
Formation  of  enamel  of,     .  125 
Filing  of,          .            .            .       278 
Prejudice  against,           ,            278 
Remarks   on,    by    Dr.    John 
Harris,              .            .            278 
Filling,              .            .            .288 
Pulp-cavity  and  root,                346 
Relative  success  in,          .      347 


Page. 
Teeth- 
Over    exposed    lining    mem- 
brane and  pulp,  .       337 
Fractures  of,           .             .  452 
Gelatinous  ingredients  of,  whence 

derived,  .  .  214 

Importance  of  attention  to  their 

cleanliness,  .  .       275 

Incisor,        ...  59 

Functions  of,  .  .         60 

Increase  of  density  in  the,  215 

Indicative  of  consumption,  219 

Influence  of  animal  food  on,  271 

.     Injury  from  neglecting  the,  153 

Irregularity  of  the,  .  159 

Liability    of,  to    disease,  deter- 
mined by  appearance  of,         206 
Membranes  of,  vascular,  .         43 

Molar,  ...  63 

Xuiiiber  of,  .  .         63 

Roots  of,  .  .  64 

Functions  of,  .  .         64 

Mounted   on   plate   with    spiral 

springs,  .  .  720 

Necrosis  of,       .  .  .       432 

Causes  of,  .  .  433 

Treatment  of,  .  .       433 

No    part  of   the,  exempt  from 

disease,  .  .  256 

Not  governed  by  the  laws  that 

regulate  other  organs,  200 

Number  of  the,  in  artificial  set,     721 
Oral,  ...  61 

Order  of  eruption  of,  .       132 

Origin  and  formation  of,  108 

Ossification   of  the,    when    first 

commenced,      .  .  109 

How  effected,  .  .       122 

Osseous  union  of,  .  186 

Peculiarities   in   formation  and 

growth  of,  .  .       181 

Permanent,  .  .  42 

Number  of,  .  .         42 

Pulp  of,  .  .  43 

Eruption  of,  .  .       147 

Curious  case  of,  .  147 

Eruption  of,      .  .  .       130 

Order  of  each  class,         .  132 

J'rocess  of,  gradual,  .       147 

When  commenced,  .  150 

Physical  characteiistics  of,  212 

Position    of,    five   j-ears    after 

birth,  .  .  145 

Predisposition  of  to  decay  in- 
creased by  improper  opera- 
tions on,  .  .  262 
Porcelain,         .            .            .       666 
Protrusion  of  lower  front,  appa- 
ratus for  correcting,           .     176 
Relations  of  upper  to  lower,  06 
Singular  aberrations  in  growth 

of  edges,         .        .         .         181 

Spontaneous  abrasion  of  cutting 

edges  of,  ...        446 

Case  of,  by  Mr.  Bell,  .     447 

Causes  of,  ...        448 

Treatment  of,        ,        .        .    449 


892 


LIBRARY 

BALTIMORE  COLLEGE  OF 

DENTAL  SURGERY 

INDEX, 


Page. 
Teeth— 

Supernumerarv,  .         .         188 

Susceptibility  of,  to  decay,  .  I'Ji) 
Teiiiporary,  ...  41 

Xumber  of,  ...       41 

And  permanent  difference  be- 
tween,       ....       65 
Laterals,  when  to  be  extracted, 155 
To  whieh  clasps  should  be  ap- 
plied, ....     758 
Transposition  of  germs  of,    .         IGl 
Why  destroyed  when  clasps  are 

applied  to,  ...     760 

Wisdom  or  dentes  sapientiaj,  64 

Teethinp^.  active  stages  of,  .         135 

Effects  of,  ....     135 

Temperaments  according   to   Lava- 

ter,  ....         208 

Difficulty    of     distinguishing 

shades  of,         .         .         .         211 
Lymphatico-serous,  .         .     218 

Temporary  teeth,  extraction  of,  411 

Eruption  of,  ...        130 

Jh'eriods  of  eruption  of  the,  .  132 
Shedding  of,  ...        139 

if  ingular  notions  with  regard 

to,  ....        139 

llow  effected,  .  .  .  139 
Theory  of  Fox,  .  .  140 
Theory  of  Laforgue,  .     140 

Theory  of  Delabarre,     .         140 
Author's  opinion  concern- 
ing, ...         142 
Third  dentition,       .        .         .        .190 
Tissue  paper  for  drying  cavity  of  a 

tooth,  .        .        .        .303 

Tonic  mouth  wash,      .        .         .        510 
Tonguf,  the,  ....       80 

Arteries  of,  ...  93 

Cha:acteristics  of,  .         .     246 

Coldness  of,  ...        249 

Coating,  .         .         .        .249 

Diminution  of,  .  .  .  247 
Enhirgement  of,  .  .  .  247 
In  chlorosis,  .        .         .        248 

In  scurvy,  ....     249 

Indicative   of  slate   of  general 

health,        .         .        .         .246 
Muscles  of,  ...  81 

Moist,  diagnosis  of,  .        .     241 

Necessity  of  noticing  appearance 

of,  in  health,  .         .         248 

Papillaj  of,         ....       80 

Pustules  on,  .         .        .         250 

Signs  of,        .         .         .        .249 


Paof. 
Tongue — 

From  secretions  of,         .  230 

Tonsil  glands,  where  situated,         .  80 

Tooth -ache,          ....  374 

Idi.vathic,         ....  379 

Causes  of,       ....  374 

Eff.ctsof,  .        .         .         .22-4 

Neuralgic,     ....  37S 

Time  lequired  to  fill  a,      .         .  308 

Tieatmont  of,         .         .         .  381 

Powder,  recipes  for,          .         .  276 

Priui:iry,  moulting  of,            .  139 

Townsend's  tiles,      ....  335 

Transposition  of  the  teeth,           .  161 

U. 

Ulceration   (  f  mucous  membrane  of 

palate,              ...  842 

Cure  of, 846 

Of  the  velum  and  uvula,        .  842 

Causes  of,      ....  844 

Treatment  of,     .         .         .  845 

Upper  jaw,  articulations  of,             .  34 

Uvula,  the,           ....  78 

Cancerous  ulcers  of,          .        .  846 

Elongation  of,        .         .         .  845 

Mercurial  ulcers  of,           .         .  844 

Scissors,  Hullihen's,      .         .  845 

Venereal  ulcers  of,            .         .  846 


Varnish  for  models,  .  .       713 

Veins  of  the  mouth,      .  .  94 

Office  of,  ...         94 

Velosynthesis,  .  .  800 

Vidian  nerve,  .  .  .98 

Velum,  inflammation  and  ulceration 

of,  .  .  .842 

W. 

Warped  plates,  how  to  restore,  766 

'  Wax-holders,           .             .  .       705 

Cleaveland's,            .             .  707 

Elliot's,             .            .  .706 

Modification  of,             .  706 

For  lower  jaw,             .  .       70S 

Wax  impressions  of  the  mouth,  704 

Manner  of  making,  .  704 
Westcott's  experiments  on  the  teeth,  273 

Whaitun,  duct  of,  .  .  73 
Wilson's  method  of  backing  teeth,     742 

Wire  plate,               .             .  .       698 

Wood  pivots,      .            .            .  687 


k. 


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